Provider Demographics
NPI:1649446485
Name:ROTH, GREGORY (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 PARK AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1953
Mailing Address - Country:US
Mailing Address - Phone:978-697-4684
Mailing Address - Fax:978-779-6167
Practice Address - Street 1:255 PARK AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1953
Practice Address - Country:US
Practice Address - Phone:978-697-4684
Practice Address - Fax:978-779-6167
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA22686OtherHPHC
MAY68133OtherBCBS
MAY61326OtherBCBS
MA4551239OtherCIGNA