# TERRY R ROTH MD PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1265601579
- **Authorized official:** TERRY R ROTH MD (OWNER)
- **Authorized official phone:** (815) 226-1906

## Contact information

- **Practice address:** 4920 E STATE ST, ROCKFORD, IL 61108-2272
- **Practice address phone:** (815) 226-1906
- **Practice address fax:** (815) 226-8474
- **Mailing address:** 4920 E STATE ST, ROCKFORD, IL 61108-2272
- **Mailing address phone:** (815) 226-1906
- **Mailing address fax:** (815) 226-8474

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 02/21/2008
- **Last updated:** 06/25/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 10132303 | BCBS | IL |
| 01 | — | 629800 | PTAN | IL |