Provider Demographics
NPI:1164705059
Name:ROTH, ANDREW JEREMIAH (DPT, OCS, SCS, ATC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JEREMIAH
Last Name:ROTH
Suffix:
Gender:M
Credentials:DPT, OCS, SCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 BIRCHWOLD RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4217
Mailing Address - Country:US
Mailing Address - Phone:617-680-2195
Mailing Address - Fax:440-516-5197
Practice Address - Street 1:29017 CHARDON RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44092-1475
Practice Address - Country:US
Practice Address - Phone:440-516-5414
Practice Address - Fax:440-516-5197
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X, 2251S0007X
OH016194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2440101Medicare PIN