Provider Demographics
NPI:1417061151
Name:ROTHMAN, SIMON (DO)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:ROTHMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BRIGGS RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-4100
Mailing Address - Country:US
Mailing Address - Phone:856-231-4774
Mailing Address - Fax:856-231-9699
Practice Address - Street 1:2201 CHAPEL AVE W
Practice Address - Street 2:ATTN: RADIOLOGY DEPARTMENT
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2048
Practice Address - Country:US
Practice Address - Phone:856-661-5473
Practice Address - Fax:856-661-5470
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB026432002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2177609Medicaid
NJ051997Medicare ID - Type Unspecified
E92216Medicare UPIN