Provider Demographics
NPI:1225179872
Name:JEFFREY A ROTHER MD PC
Entity Type:Organization
Organization Name:JEFFREY A ROTHER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROTHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-224-2900
Mailing Address - Street 1:1221 G ST NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1812
Mailing Address - Country:US
Mailing Address - Phone:580-224-2900
Mailing Address - Fax:580-224-0009
Practice Address - Street 1:1221 G ST NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1812
Practice Address - Country:US
Practice Address - Phone:580-224-2900
Practice Address - Fax:580-224-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17679207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100101430AMedicaid
442605098PMedicare PIN
OK100101430AMedicaid