Healthcare Provider Details

I. General information

NPI: 1164094843
Provider Name (Legal Business Name): MARY EILEEN ROTH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY EILEEN GERARDO

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 W HUBBARD ST
CHICAGO IL
60654-4407
US

IV. Provider business mailing address

2446 N RACINE AVE APT 1F
CHICAGO IL
60614-3404
US

V. Phone/Fax

Practice location:
  • Phone: 312-222-2570
  • Fax:
Mailing address:
  • Phone: 804-658-8536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209034461
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: