Individual
GLENN A KOTNIK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2600 GREENBUSH ST, LAFAYETTE, IN 47904-2477
(765) 448-8000
Mailing address
PO BOX 5545, LAFAYETTE, IN 47903-5545
(765) 448-8000
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
01039473A
IN
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
01039473A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000085315
ANTHEM
IN
01
—
000000586104
ANTHEM PROVIDER NUMBER
IN
05
—
100360710
—
IN
Enumeration date
08/27/2006
Last updated
09/04/2009
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