Provider Demographics
NPI:1538677026
Name:HAROLD F. ROTH, D.O.
Entity Type:Organization
Organization Name:HAROLD F. ROTH, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-485-1789
Mailing Address - Street 1:1627 LAKE LANSING RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3788
Mailing Address - Country:US
Mailing Address - Phone:517-485-1789
Mailing Address - Fax:517-485-2357
Practice Address - Street 1:1627 LAKE LANSING RD STE 200
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3788
Practice Address - Country:US
Practice Address - Phone:517-485-1789
Practice Address - Fax:517-485-2357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007838208D00000X
MI4704259692363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1023005659Medicaid