Individual
TERRY ROTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
4920 EAST STATE ST, ROCKFORD, IL 61108
(815) 226-1906
(815) 226-8474
Mailing address
4920 EAST STATE ST, ROCKFORD, IL 61108
(815) 226-1906
(815) 226-8474
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
36059503
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0010100550
BCBS
IL
01
—
009771
HEALTH ALLIANCE
IL
05
—
036059503
—
IL
01
—
791133579
RETIRED RAILROAD
IL
Enumeration date
11/18/2005
Last updated
05/22/2008
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