1699772673 NPI number — JOHN D ROTH M.D.

Table of content: JOHN D ROTH M.D. (NPI 1699772673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699772673 NPI number — JOHN D ROTH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
JOHN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699772673
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4133 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROAD TOP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16621-9001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-635-2916
Provider Business Mailing Address Fax Number:
814-635-2918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4133 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROAD TOP
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16621-9001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-635-2916
Provider Business Practice Location Address Fax Number:
814-635-2918
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD047424L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 007017627-0005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 206707 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 007017627-0002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007017627-0006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30802890 . This is a "AMERIHEALTH CARITAS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 007017627-0010 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30803027 . This is a "AMERIHEALTH CARITAS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000742911 . This is a "HIGHMARK BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 007017627-0004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30802932 . This is a "AMERIHEALTH CARITAS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 007017627-0007 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007017627-0009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7715310 . This is a "AETNA / COVENTRY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30802912 . This is a "AMERIHEALTH CARITAS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30707170 . This is a "AMERIHEALTH CARITAS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P02157142 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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