1427189075 NPI number — MISS STACY ANNE ROTH RD, LDN, MPH

Table of content: MISS STACY ANNE ROTH RD, LDN, MPH (NPI 1427189075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427189075 NPI number — MISS STACY ANNE ROTH RD, LDN, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
STACY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
RD, LDN, MPH
Provider Gender Code:
F

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:
1427189075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9039 W CHURCH ST
Provider Second Line Business Mailing Address:
APT 1H
Provider Business Mailing Address City Name:
DES PLAINES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60016-7008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-201-3847
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9039 W CHURCH ST
Provider Second Line Business Practice Location Address:
APT 1H
Provider Business Practice Location Address City Name:
DES PLAINES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60016-7008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-201-3847
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2007

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: 133V00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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