Basic Information
| Provider Information | |||||||||
| NPI: | 1790731651 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOTOV | ||||||||
| FirstName: | PETIO | ||||||||
| MiddleName: | VLADIMIROV | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CAMPUS DR. | ||||||||
| Address2: | |||||||||
| City: | HANCOCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499301569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9060483100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028470000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 4301087243 | MI | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZC0500X | 042-0015453 | VT | Y | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
ID Information
| ID | Type | State | Issuer | Description | 0829560001 | 01 | MI | MEDICARE DME | OTHER | 4968078 | 05 | MI | MEDICAID | PK087243 | 01 | MI | BLUE CROSS STATE ID | OTHER | 0C16002 | 01 | MI | MEDICARE GROUP | OTHER |