Provider Demographics
NPI:1649503327
Name:KRISTIANSSON ROTH PC
Entity type:Organization
Organization Name:KRISTIANSSON ROTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIANSSON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:912-409-9879
Mailing Address - Street 1:4445 HWY 40
Mailing Address - Street 2:SATURDAY PARK 503
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-4099
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4445 HWY 40
Practice Address - Street 2:SATURDAY PARK 503
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-4099
Practice Address - Country:US
Practice Address - Phone:912-409-9879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002706103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA118222317BMedicaid