1023287695 NPI number — ROBERT ROTH MD A PROFESSIONAL

Table of content: (NPI 1023287695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023287695 NPI number — ROBERT ROTH MD A PROFESSIONAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT ROTH MD A PROFESSIONAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1023287695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2647 BOX CANYON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89128-0450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-363-5575
Provider Business Mailing Address Fax Number:
702-646-1727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2647 BOX CANYON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89128-0450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-363-5575
Provider Business Practice Location Address Fax Number:
702-646-1727
Provider Enumeration Date:
02/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NUSS
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLER/CODER
Authorized Official Telephone Number:
702-363-5575

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  8797 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: V101524 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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