1366441099 NPI number — JAYNE M ROTH CNM

Table of content: JAYNE M ROTH CNM (NPI 1366441099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366441099 NPI number — JAYNE M ROTH CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
JAYNE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366441099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2142 N COVE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43606-3895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-291-3604
Provider Business Mailing Address Fax Number:
419-479-6971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2142 N COVE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43606-3895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-291-3604
Provider Business Practice Location Address Fax Number:
419-479-6971
Provider Enumeration Date:
07/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  08128 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: NM-08128 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4691024 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000358994 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 344428256053 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2534887 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344428256 . This is a "BEECHSTREET" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4691033 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05225 . This is a "PARAMOUNT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 344428256 . This is a "FRONTPATH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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