Provider Demographics
NPI:1063733053
Name:ROTH, BENJAMIN STEELE (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:STEELE
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6400
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-797-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336.094032207P00000X
IL125-058613207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine