MEDICARE: LISA ANNE ROTH MD

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	2084P0804X	Child & Adolescent Psychiatry Physician	MD293829	NY

General Provider Information

NPI Number	:	1679986715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ANNE ROTH MD

Provider Business Mailing Address
First Line	:	291 BROADWAY RM 710
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10007-1928
Country	:	US
Telephone Number	:	917-719-6156
Fax Number	:	347-270-8747

Provider Business Practice Location Address
First Line	:	291 BROADWAY RM 710
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10007-1928
Country	:	US
Telephone Number	:	917-719-6156
Fax Number	:	347-270-8747

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

Provider Enumeration Date	:	06/06/2014
Last Update Date	:	09/27/2023

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