Provider Demographics
NPI:1740496660
Name:ROTH, BRUCE JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JOSEPH
Last Name:ROTH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:800-647-2098
Mailing Address - Fax:314-362-3192
Practice Address - Street 1:5225 MID AMERICA PLZ
Practice Address - Street 2:DIV IM MEDICAL ONCOLOGY, STE D115
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-0002
Practice Address - Country:US
Practice Address - Phone:800-647-2098
Practice Address - Fax:314-362-3192
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010008626207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204198808Medicaid
MO1740496660Medicaid