Provider Demographics
NPI:1215919816
Name:ROTH, TERRY
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 EAST STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:815-226-1906
Mailing Address - Fax:815-226-8474
Practice Address - Street 1:4920 EAST STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-226-1906
Practice Address - Fax:815-226-8474
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360595032084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010100550OtherBCBS
IL791133579OtherRETIRED RAILROAD
IL009771OtherHEALTH ALLIANCE
IL036059503Medicaid
IL629800Medicare ID - Type Unspecified
IL009771OtherHEALTH ALLIANCE