Healthcare Provider Details

I. General information

NPI: 1982925327
Provider Name (Legal Business Name): ELIZABETH B ROTH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC UROLOGY
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE PEDIATRIC UROLOGY
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-3794
  • Fax: 414-266-1752
Mailing address:
  • Phone: 414-266-3794
  • Fax: 414-266-1752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number63705
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number63705
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: