Provider Demographics
NPI:1265601579
Name:TERRY R ROTH MD PC
Entity type:Organization
Organization Name:TERRY R ROTH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-226-1906
Mailing Address - Street 1:4920 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2272
Mailing Address - Country:US
Mailing Address - Phone:815-226-1906
Mailing Address - Fax:815-226-8474
Practice Address - Street 1:4920 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2272
Practice Address - Country:US
Practice Address - Phone:815-226-1906
Practice Address - Fax:815-226-8474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10132303OtherBCBS
IL629800OtherPTAN
IL629800OtherPTAN