Basic Information
| Provider Information | |||||||||
| NPI: | 1811945074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTELLO | ||||||||
| FirstName: | LEO | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791372 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212791372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016088375 | ||||||||
| FaxNumber: | 3016083979 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 OLD GEORGETOWN RD | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208141422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018963100 | ||||||||
| FaxNumber: | 3018962393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 08/28/2009 | ||||||||
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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 | 207RC0200X | D0052774 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 415096100 | 05 | MD | MEDICAID | P00418895 | 01 | MD | MEDICARE RAILROAD | OTHER | 54824901 | 01 | MD | CAREFIRST BCBS | OTHER | 234910800 | 05 | MD | MEDICAID | 54824902 | 01 | MD | CAREFIRST BCBS | OTHER | 74960001 | 01 | DC | CAREFIRST BCBS | OTHER | 19460007 | 01 | DC | CAREFIRST BCBS | OTHER | 034470600 | 05 | DC | MEDICAID |