Provider Demographics
NPI:1891781381
Name:ROTH AND RUSSIN LLC
Entity Type:Organization
Organization Name:ROTH AND RUSSIN LLC
Other - Org Name:MAIN LINE EYE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:610-687-6888
Mailing Address - Street 1:124 BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3929
Mailing Address - Country:US
Mailing Address - Phone:610-687-6888
Mailing Address - Fax:610-687-1120
Practice Address - Street 1:124 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3929
Practice Address - Country:US
Practice Address - Phone:610-687-6888
Practice Address - Fax:610-687-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA086046Medicare PIN