Basic Information
| Provider Information | |||||||||
| NPI: | 1609262161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTTI | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOTTI | ||||||||
| OtherFirstName: | BRYAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3803 W CHESTER PIKE STE 160 | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190732336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843371530 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 135 S BRYN MAWR AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103251390 | ||||||||
| FaxNumber: | 6103251373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2015 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD463061 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | MD463061 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.