1750480356 NPI number — DR. ADELE M. ROTH M.D.

Table of content: DR. ADELE M. ROTH M.D. (NPI 1750480356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750480356 NPI number — DR. ADELE M. ROTH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
ADELE
Provider Middle Name:
M.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RALL
Provider Other First Name:
ADELE
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1750480356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2900 FRANK SCOTT PKWY W STE 980
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62223-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-234-9200
Provider Business Mailing Address Fax Number:
618-234-3940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 FRANK SCOTT PKWY W
Provider Second Line Business Practice Location Address:
SUITE 980
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62223-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-234-9200
Provider Business Practice Location Address Fax Number:
618-234-3940
Provider Enumeration Date:
09/21/2006

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: 207Q00000X , with the licence number:  036069016 , 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)

  • Identifier: 036069016 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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