Individual
GARY F ROTH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2200 E WASHINGTON ST, BLOOMINGTON, IL 61701-4364
(309) 661-5111
Mailing address
2538 MOMENTUM PL, CHICAGO, IL 60689-0001
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
036052934
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036052934
—
IL
Enumeration date
06/27/2006
Last updated
09/18/2009
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