Provider Demographics
NPI:1144538513
Name:PHILIP A. ROTH, JR., MD/PC
Entity type:Organization
Organization Name:PHILIP A. ROTH, JR., MD/PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:256-533-3966
Mailing Address - Street 1:420 LOWELL DR SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3754
Mailing Address - Country:US
Mailing Address - Phone:256-535-5940
Mailing Address - Fax:256-535-5954
Practice Address - Street 1:2089 CECIL ASHBURN DR SE
Practice Address - Street 2:SUITE 101
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-2567
Practice Address - Country:US
Practice Address - Phone:256-533-3966
Practice Address - Fax:256-533-9652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0004036975OtherAETNA
AL080055438OtherRAILROAD MEDICARE
AL000085204Medicaid
AL510-85204OtherBLUE CROSS BLUE SHIELD
AL080055438OtherRAILROAD MEDICARE
ALC72761Medicare UPIN