Basic Information
| Provider Information | |||||||||
| NPI: | 1558386607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTT-KOTHARI | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| OtherLastName: | BOTT | ||||||||
| OtherFirstName: | TERRI | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5950 METRO WAY SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162528160 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 11/19/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 077359 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 4301077359 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4284064 | 05 | MI | MEDICAID | 920006063 | 01 | MI | RAILROAD MEDICARE | OTHER |