Provider Demographics
NPI:1710968383
Name:ROTH, PHILIP ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:ANTHONY
Last Name:ROTH
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 1:420 LOWELL DR SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3754
Mailing Address - Country:US
Mailing Address - Phone:256-535-5940
Mailing Address - Fax:256-882-9757
Practice Address - Street 1:2089 CECIL ASHBURN DR SE
Practice Address - Street 2:SUITE 101
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-2567
Practice Address - Country:US
Practice Address - Phone:256-533-3966
Practice Address - Fax:256-882-9757
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080055438OtherRAILROAD MEDICARE
AL000085204Medicaid
0004036975OtherAETNA
AL51085204OtherBLUE CROSS BLUE SHIELD
AL000085204Medicaid
AL51085204OtherBLUE CROSS BLUE SHIELD