Healthcare Provider Details

I. General information

NPI: 1205843471
Provider Name (Legal Business Name): ELLIOT ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 E ERIE ST
CHICAGO IL
60611-3167
US

IV. Provider business mailing address

355 E ERIE ST
CHICAGO IL
60611-3167
US

V. Phone/Fax

Practice location:
  • Phone: 312-238-1000
  • Fax: 312-238-1417
Mailing address:
  • Phone: 312-238-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number036-067061
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036-067061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: