1144210279 NPI number — DR. MARK D ROTH MD

Table of content: DR. MARK D ROTH MD (NPI 1144210279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144210279 NPI number — DR. MARK D ROTH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
MARK
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1144210279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
785 5TH AVENUE
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
CHAMBERSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17201-4232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-263-9555
Provider Business Mailing Address Fax Number:
717-217-4217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 ROADSIDE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYNESBORO
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17268-2542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-762-7155
Provider Business Practice Location Address Fax Number:
717-762-6929
Provider Enumeration Date:
10/28/2005

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: 208600000X , with the licence number:  MD060014L , 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: 25-1716306 . This is a "MULTIPLAN/PHCS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 546216-01 . This is a "MD BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 367632 . This is a "MAMSI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 6720367 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 867633 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00700657 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02195701 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "INFORMED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "DEVON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "HEALTHNET/TRICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 990003822 . This is a "MEDICARE RAILROAD RETIRE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007307260034 . This is a "MEDICAID GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "GREATWEST HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5234477 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "SOUTH CENTRAL PREFERRED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 257729 . This is a "UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 908528 . This is a "HIGHMARK BLUESHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: G920-0109/233CCU . This is a "CAREFIRST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: MD060014L . This is a "LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0016462400002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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