Healthcare Provider Details

I. General information

NPI: 1538677026
Provider Name (Legal Business Name): HAROLD F. ROTH, D.O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1627 LAKE LANSING RD STE 200
LANSING MI
48912-3788
US

IV. Provider business mailing address

1627 LAKE LANSING RD STE 200
LANSING MI
48912-3788
US

V. Phone/Fax

Practice location:
  • Phone: 517-485-1789
  • Fax: 517-485-2357
Mailing address:
  • Phone: 517-485-1789
  • Fax: 517-485-2357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101007838
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704259692
License Number StateMI

VIII. Authorized Official

Name: DR. HAROLD FRANKLIN ROTH
Title or Position: PROVIDER
Credential: DO
Phone: 517-485-1789