Provider Demographics
NPI:1699951293
Name:MORRIS MEDICAL CENTER, LTD.
Entity type:Organization
Organization Name:MORRIS MEDICAL CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:815-942-0683
Mailing Address - Street 1:107 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-2128
Mailing Address - Country:US
Mailing Address - Phone:815-942-0683
Mailing Address - Fax:815-942-5624
Practice Address - Street 1:107 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-2128
Practice Address - Country:US
Practice Address - Phone:815-942-0683
Practice Address - Fax:815-942-5624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC40424Medicare UPIN
IL211030Medicare PIN