1932102985 NPI number — DR. MARK TERRY ROTHSTEIN M.D.

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	ROTHSTEIN
Provider First Name	:	MARK
Provider Middle Name	:	TERRY
Provider Name Prefix Text	:	DR.
Provider Name Suffix Text	:
Provider Credential Text	:	M.D.
Provider Gender Code	:	M

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	:	1932102985
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
NPI Reactivation Date	:

Provider First Line Business Mailing Address	:	101 S SHAFER ST
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	ATHENS
Provider Business Mailing Address State Name	:	OH
Provider Business Mailing Address Postal Code	:	457012351
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	7405924491
Provider Business Mailing Address Fax Number	:	7405924844

Provider First Line Business Practice Location Address	:	101 S SHAFER ST
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	ATHENS
Provider Business Practice Location Address State Name	:	OH
Provider Business Practice Location Address Postal Code	:	457012351
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	7405924491
Provider Business Practice Location Address Fax Number	:	7405924844
Provider Enumeration Date	:	05/23/2005

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

• Taxonomy code: 207Q00000X , with the licence number:  MD011535 , registered in the state of HI .
• Taxonomy code: 207Q00000X , with the licence number: 35-037876 , registered in the state of OH .

• Identifier: 000000117513 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "".
• Identifier: 0691461 . This is a "UNITED MINE WORKERS" identifier . This identifiers is of the category "".
• Identifier: A75189 . This identifiers is of the category "".
• Identifier: 0259134 , issued by the state of ( OH ) . This identifiers is of the category "".
• Identifier: RO0408502 . This identifiers is of the category "".