Provider Demographics
NPI:1497958938
Name:ROTH EAR, NOSE & THROAT ASSOCIATES PC
Entity Type:Organization
Organization Name:ROTH EAR, NOSE & THROAT ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-676-4550
Mailing Address - Street 1:PO BOX 63147
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-0947
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052327L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA766316Medicare ID - Type Unspecified
PAE78505Medicare UPIN