Healthcare Provider Details

I. General information

NPI: 1174503866
Provider Name (Legal Business Name): TED M. ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 MEMORIAL DR STE 302
SOUTH BEND IN
46601-1073
US

IV. Provider business mailing address

1115 BURNS ST
SOUTH BEND IN
46617-4403
US

V. Phone/Fax

Practice location:
  • Phone: 574-367-3800
  • Fax: 574-367-3801
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01081226A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number01081226A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: