Provider Demographics
NPI:1497747323
Name:ROTH, CHRISTIAN WILLIAM (PT, CHT)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:WILLIAM
Last Name:ROTH
Suffix:
Gender:M
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1407
Practice Address - Country:US
Practice Address - Phone:248-486-1110
Practice Address - Fax:248-486-3318
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501000577225100000X, 2251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4709236Medicaid
MI0H71069OtherBCBSMI
MI0H71069OtherBCBSMI
MIMI6211089Medicare PIN
MIN69750101Medicare PIN
MI4709236Medicaid