Basic Information
| Provider Information | |||||||||
| NPI: | 1578596110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELLEN M. ROTBLATT, M.D., P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 SOUTH MAIN STREET | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344543560 | ||||||||
| FaxNumber: | 7344543570 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 SOUTH MAIN STREET | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344543560 | ||||||||
| FaxNumber: | 7344543570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROTBLATT | ||||||||
| AuthorizedOfficialFirstName: | ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, BOARD CERTIFIED PSYCHIAT | ||||||||
| AuthorizedOfficialTelephone: | 7344543560 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301052943 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 11287336 | 01 | MI | CAQH | OTHER | 4301052943 | 01 | MI | MEDICAL LICENSE NUMBER MI | OTHER | 2084P0800X | 01 | MI | MEDICAL DR. TAXONOMY # | OTHER | F16401 | 01 | MI | MEDICARE OPTED-OUT UPIN | OTHER | 193400000X | 01 | MI | NPI SINGLE SPECIALTY TAXONOMY NUMBER | OTHER |