Basic Information
| Provider Information | |||||||||
| NPI: | 1851348247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOTLYAROV | ||||||||
| FirstName: | EDUARD | ||||||||
| MiddleName: | VOLFOVITCH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32627 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482320627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667441452 | ||||||||
| FaxNumber: | 5864124101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1375 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAPEER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484461350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106675500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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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 | 2085N0904X | 0101032700 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085N0904X | D0026059 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085N0904X | 4301061744 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085N0904X | MD11451 | DC | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | D0026059 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0101032700 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 4301061744 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD11451 | DC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2965193 | 05 | MI | MEDICAID | 300049506 | 01 | MI | RRMC | OTHER | 310D460020 | 01 | MI | BCBS GROUP PIN | OTHER | 3006399421 | 01 | MI | BCBS PIN # | OTHER | CA5318 | 01 | MI | MEDICARE RR GROUP PIN | OTHER | 2965228 | 05 | MI | MEDICAID |