Provider Demographics
NPI:1750480356
Name:ROTH, ADELE M (MD)
Entity Type:Individual
Prefix:DR
First Name:ADELE
Middle Name:M
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:ADELE
Other - Middle Name:M
Other - Last Name:RALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W STE 980
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-234-9200
Mailing Address - Fax:618-234-3940
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 980
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-234-9200
Practice Address - Fax:618-234-3940
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069016Medicaid
IL0821523294OtherBC/BS OF ILLINOIS
IL036069016Medicaid
IL0821523294OtherBC/BS OF ILLINOIS