Healthcare Provider Details

I. General information

NPI: 1053574954
Provider Name (Legal Business Name): MARLENE MARGARET ROTH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31815 SOUTHFIELD RD SUITE 14
BEVERLY HILLS MI
48025-5471
US

IV. Provider business mailing address

31815 SOUTHFIELD RD STE 10
BEVERLY HILLS MI
48025-5471
US

V. Phone/Fax

Practice location:
  • Phone: 248-644-2700
  • Fax: 248-644-4783
Mailing address:
  • Phone: 248-644-2700
  • Fax: 248-644-4783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301067678
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: