Provider Demographics
NPI:1205996329
Name:HERBERT J ROTH AND KALPANA SHAH MD PC
Entity type:Organization
Organization Name:HERBERT J ROTH AND KALPANA SHAH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:248-644-5626
Mailing Address - Street 1:31815 SOUTHFIELD RD
Mailing Address - Street 2:STE 14
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5471
Mailing Address - Country:US
Mailing Address - Phone:248-644-5626
Mailing Address - Fax:248-644-5497
Practice Address - Street 1:31815 SOUTHFIELD RD
Practice Address - Street 2:STE 14
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5471
Practice Address - Country:US
Practice Address - Phone:248-644-5626
Practice Address - Fax:248-644-5497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI024195208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3289487Medicaid
MI3289496Medicaid