1730327818 NPI number — SHARI ROTH, MD, LLC

Table of content: (NPI 1730327818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730327818 NPI number — SHARI ROTH, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHARI ROTH, MD, LLC
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:
1730327818
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 415
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06095-0415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-925-6463
Provider Business Mailing Address Fax Number:
860-925-6120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 WOODLAND ST STE 222
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06105-4318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-523-1900
Provider Business Practice Location Address Fax Number:
860-247-3347
Provider Enumeration Date:
01/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ROTH
Authorized Official First Name:
SHARI
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
860-523-1900

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  032607 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001326075 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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