Provider Demographics
NPI:1477512689
Name:ROTH, MAURICE (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9150 MARSHALL ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-2217
Mailing Address - Country:US
Mailing Address - Phone:215-676-4550
Mailing Address - Fax:215-676-4711
Practice Address - Street 1:9150 MARSHALL ST
Practice Address - Street 2:SUITE 4
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2217
Practice Address - Country:US
Practice Address - Phone:215-676-4550
Practice Address - Fax:215-676-4711
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052327L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E78505Medicare UPIN
766316Medicare ID - Type Unspecified