Basic Information
| Provider Information | |||||||||
| NPI: | 1558324590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTTO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1951 BENCH RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082372080 | ||||||||
| FaxNumber: | 2082371084 | ||||||||
| Practice Location | |||||||||
| Address1: | 1951 BENCH RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082372080 | ||||||||
| FaxNumber: | 2082371084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 03/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | RPT186 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 002682600 | 05 | ID | MEDICAID | 000010020633 | 01 | ID | GCPT REGENCE OF ID | OTHER | T1385 | 01 | ID | GCPT BLUE CROSS OF ID | OTHER |