Provider Demographics
NPI:1831190917
Name:MICHAEL A ROTH MD PC
Entity type:Organization
Organization Name:MICHAEL A ROTH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:ATWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-347-6100
Mailing Address - Street 1:42450 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3030
Mailing Address - Country:US
Mailing Address - Phone:248-347-6100
Mailing Address - Fax:
Practice Address - Street 1:42450 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3013
Practice Address - Country:US
Practice Address - Phone:248-347-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6167310Medicaid
MI0P54650Medicare PIN
MIP54650001Medicare PIN