1457566101 NPI number — MATT D ROTH MD

Table of content: MATT D ROTH MD (NPI 1457566101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457566101 NPI number — MATT D ROTH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
MATT
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1457566101
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:
660 BEAVER CREEK CIR
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
MAUMEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43537-1745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-891-6210
Provider Business Mailing Address Fax Number:
419-893-3232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2865 N REYNOLDS RD STE 260
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:
43615-2070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-578-4280
Provider Business Practice Location Address Fax Number:
419-537-5684
Provider Enumeration Date:
05/14/2007

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: 207QS0010X , with the licence number:  35-088737 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 35088737 , 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: 2769839 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05455 . This is a "PARAMOUNT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9202151 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000571949 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "RRMC" identifier . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".




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