Healthcare Provider Details

I. General information

NPI: 1205996329
Provider Name (Legal Business Name): HERBERT J ROTH AND KALPANA SHAH MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 248-644-5626
  • Fax: 248-644-5497
Mailing address:
  • Phone: 248-644-5626
  • Fax: 248-644-5497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number024195
License Number StateMI

VIII. Authorized Official

Name: DR. HERBERT J ROTH SR.
Title or Position: PRESIDENT
Credential: MD
Phone: 248-644-5626