1144538513 NPI number — PHILIP A. ROTH, JR., MD/PC

Table of content: (NPI 1144538513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144538513 NPI number — PHILIP A. ROTH, JR., MD/PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILIP A. ROTH, JR., MD/PC
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:
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:
1144538513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 LOWELL DR SE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35801-3754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-535-5940
Provider Business Mailing Address Fax Number:
256-535-5954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2089 CECIL ASHBURN DR SE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35802-2567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-533-3966
Provider Business Practice Location Address Fax Number:
256-533-9652
Provider Enumeration Date:
09/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ROTH
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
256-533-3966

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  12141 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0004036975 . This is a "AETNA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 080055438 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000085204 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 510-85204 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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