Provider Demographics
NPI:1538220447
Name:ROTH, KIMBERLY RAQUEL (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAQUEL
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 1:200 LOTHROP ST
Mailing Address - Street 2:FORBES TOWER SUITE 9055
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213
Mailing Address - Country:US
Mailing Address - Phone:412-647-3087
Mailing Address - Fax:412-647-4486
Practice Address - Street 1:4401 PENN AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1334
Practice Address - Country:US
Practice Address - Phone:412-692-7692
Practice Address - Fax:412-692-7464
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4304362080P0204X
PAMD074363L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
I27173Medicare UPIN