Provider Demographics
NPI:1508866377
Name:ROTHROCK, ROBERT W (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:ROTHROCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 SOUTH ST
Mailing Address - Street 2:TUTTLEMAN BUILDING, 2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-7411
Mailing Address - Country:US
Mailing Address - Phone:215-893-7256
Mailing Address - Fax:215-893-7236
Practice Address - Street 1:1840 SOUTH ST
Practice Address - Street 2:TUTTLEMAN BUILDING, 2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-7411
Practice Address - Country:US
Practice Address - Phone:215-893-7256
Practice Address - Fax:215-893-7236
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001275L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS13853Medicare UPIN
PA047952Medicare ID - Type Unspecified