1164730214 NPI number — JOHN ROTH, DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164730214 NPI number — JOHN ROTH, DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN ROTH, DPM
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:
1164730214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 E ROLLING CROSSROADS
Provider Second Line Business Mailing Address:
SUITE 55
Provider Business Mailing Address City Name:
CATONSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21228-6211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-455-9660
Provider Business Mailing Address Fax Number:
410-455-9665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 E ROLLING CROSSROADS
Provider Second Line Business Practice Location Address:
SUITE 55
Provider Business Practice Location Address City Name:
CATONSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21228-6211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-455-9660
Provider Business Practice Location Address Fax Number:
410-455-9665
Provider Enumeration Date:
09/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ROTH
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-455-9660

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  00679 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31463 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 77530002 . This is a "CAREFIRST BLUECHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 408078500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 27-00297 . This is a "UNITED HEALTHCARE OF MID-ATLANTIC" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 4309156 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: T210 . This is a "CAREFIRST BLUECROSS BLUESHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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