Provider Demographics
NPI:1942257399
Name:OTTENWELLER, STEVEN (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:OTTENWELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2750 E BELTLINE AVE NE
Practice Address - Street 2:ATTN: OCC HEALTH OFFICE
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-8614
Practice Address - Country:US
Practice Address - Phone:616-447-5870
Practice Address - Fax:616-391-7733
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301032879208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B45613Medicare UPIN
MI0M74460222Medicare PIN
MI0D16150160Medicare ID - Type Unspecified