Provider Demographics
NPI:1912973389
Name:ROTH, SARA L (MD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:L
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36115 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:734-464-0887
Mailing Address - Fax:734-402-0254
Practice Address - Street 1:1105 6TH STREET
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-947-0673
Practice Address - Fax:801-740-2847
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014990207PE0004X, 207R00000X
MN58841208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4780797Medicaid
MISR014990OtherBLUE CROSS BLUE SHIELD
MII41686Medicare UPIN
MISR014990OtherBLUE CROSS BLUE SHIELD