MEDICARE: JOHN B. ROTH JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	036044899	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447396361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN B. ROTH JR. M.D.

Provider Business Mailing Address
First Line	:	107 W JEFFERSON ST
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-2128
Country	:	US
Telephone Number	:	815-942-0683
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 W JEFFERSON ST
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-2128
Country	:	US
Telephone Number	:	815-942-0683
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	09/21/2011

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