Provider Demographics
NPI:1952767782
Name:ROTH, BAILEY R
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:R
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 N VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1486
Mailing Address - Country:US
Mailing Address - Phone:815-953-1019
Mailing Address - Fax:
Practice Address - Street 1:380 N VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1486
Practice Address - Country:US
Practice Address - Phone:815-953-1019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program