Terry R Roth MD PC

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

Legal business name

TERRY R ROTH MD PC

Practice address

4920 E State St
Rockford, IL 61108-2272

Phone

(815) 226-1906

Fax

(815) 226-8474

NPI assigned

Feb 21, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Terry R Roth, MD

Title

Owner

Phone

(815) 226-1906

Specialties & licenses 1

Addresses

Other identifiers 2

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1203552000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1435190400000",
    "number": "1265601579",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4920 E STATE ST",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611082272",
            "telephone_number": "815-226-1906",
            "fax_number": "815-226-8474"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4920 E STATE ST",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611082272",
            "telephone_number": "815-226-1906",
            "fax_number": "815-226-8474"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TERRY R ROTH MD PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-21",
        "last_updated": "2015-06-25",
        "status": "A",
        "authorized_official_last_name": "ROTH",
        "authorized_official_first_name": "TERRY",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "815-226-1906",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "10132303",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "629800",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinic/Center in Rockford, IL
• Providers in Rockford, IL by specialty
• Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.