Provider Demographics
NPI:1760676795
Name:KATHERINE A ROTH MD PLC
Entity Type:Organization
Organization Name:KATHERINE A ROTH MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-0848
Mailing Address - Street 1:820 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2466
Mailing Address - Country:US
Mailing Address - Phone:231-935-0848
Mailing Address - Fax:231-935-0846
Practice Address - Street 1:820 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2466
Practice Address - Country:US
Practice Address - Phone:231-935-0848
Practice Address - Fax:231-935-0846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-03
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046406261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care