Provider Demographics
NPI:1548242712
Name:ROH, MICHAEL SOO (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SOO
Last Name:ROH
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:PO BOX 735263 SUITE 300
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2902 MCFARLAND RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6801
Practice Address - Country:US
Practice Address - Phone:815-316-2100
Practice Address - Fax:815-316-2099
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105970207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105970 2Medicaid
ILL99576Medicare ID - Type Unspecified
ILH40751Medicare UPIN