Basic Information
| Provider Information | |||||||||
| NPI: | 1588657779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLTUCH | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER ROAD | ||||||||
| Address2: | MSC 9152 | ||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866299 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVENUE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404231356 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 06/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35038688 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0304914 | 01 | OH | BCMH | OTHER | 4230665 | 01 | OH | AETNA | OTHER | 735110 | 01 | OH | BUCKEYE | OTHER | 000000516213 | 01 | OH | ANTHEM | OTHER | 000000221019 | 01 | OH | UNISON | OTHER | P00405346 | 01 | OH | RAILROAD MEDICARE | OTHER | 0312852 | 05 | OH | MEDICAID | 363371 | 01 | OH | WELLCARE | OTHER |