Healthcare Provider Details

I. General information

NPI: 1629063524
Provider Name (Legal Business Name): MICHAEL THOMAS ROTHERMICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N STURGEON ST
MONTGOMERY CITY MO
63361-1829
US

IV. Provider business mailing address

PO BOX 19
HERMANN MO
65041-0019
US

V. Phone/Fax

Practice location:
  • Phone: 573-564-2990
  • Fax:
Mailing address:
  • Phone: 573-486-1193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2002011778
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: