Organization
TERRY R ROTH MD PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TERRY R ROTH MD (OWNER)
(815) 226-1906
Entity
Organization
Contact information
Practice address
4920 E STATE ST, ROCKFORD, IL 61108-2272
(815) 226-1906
(815) 226-8474
Mailing address
4920 E STATE ST, ROCKFORD, IL 61108-2272
(815) 226-1906
(815) 226-8474
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10132303
BCBS
IL
01
—
629800
PTAN
IL
Enumeration date
02/21/2008
Last updated
06/25/2015
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