Active NPI
Carolyn Roth, N.P.
- Nurse Practitioner
- Bloomington, IL
National Provider Identifier
1679609630
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Nurse Practitioner
- License
- 209000155
- Practice address
- 1701 E College Ave
Bloomington, IL 61704-2101 - Phone
- (309) 664-3038
- NPI assigned
- Feb 26, 2007
- Last updated
- Nov 20, 2009
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nurse Practitioner | 363L00000X | 209000155 | IL | Primary |
Addresses
Primary practice location
1701 E College Ave
Bloomington, IL 61704-2101
Mailing address
1701 E College Ave
Bloomington, IL 61704-2101
Phone (309) 664-3000
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| IL2613 | Other | IL | MEDICARE GROUP PTAN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 209000155 | IL | MD | Nurse Practitioner |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172448000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1258675200000",
"number": "1679609630",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1701 E COLLEGE AVE",
"city": "BLOOMINGTON",
"state": "IL",
"postal_code": "617042101",
"telephone_number": "309-664-3000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1701 E COLLEGE AVE",
"city": "BLOOMINGTON",
"state": "IL",
"postal_code": "617042101",
"telephone_number": "309-664-3038"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROTH",
"first_name": "CAROLYN",
"credential": "N.P.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-02-26",
"last_updated": "2009-11-20",
"status": "A"
},
"taxonomies": [
{
"code": "363L00000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner",
"state": "IL",
"license": "209000155",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE GROUP PTAN",
"identifier": "IL2613",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Bloomington, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 20, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.