Provider Demographics
NPI:1386918001
Name:ROTH, MARC (MSPT)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:MOSHE
Other - Middle Name:
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSPT
Mailing Address - Street 1:6503 HAL COURT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209
Mailing Address - Country:US
Mailing Address - Phone:410-653-9524
Mailing Address - Fax:
Practice Address - Street 1:6503 HAL COURT
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209
Practice Address - Country:US
Practice Address - Phone:443-857-9209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD209692251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics