Provider Demographics
NPI:1033323712
Name:HERBERT J. ROTH JR. MD PC
Entity Type:Organization
Organization Name:HERBERT J. ROTH JR. MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:248-457-9190
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DRAWER 242401
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2424
Mailing Address - Country:US
Mailing Address - Phone:248-457-9190
Mailing Address - Fax:248-457-9188
Practice Address - Street 1:201 W. BIG BEAVER RD
Practice Address - Street 2:SUITE 1060
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4100
Practice Address - Country:US
Practice Address - Phone:248-457-9190
Practice Address - Fax:248-457-9188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407009207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF31058Medicare UPIN
0P03300Medicare ID - Type Unspecified