=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497747323
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN WILLIAM ROTH PT, CHT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2005
-----------------------------------------------------
Last Update Date | 11/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 S LAFAYETTE ST
-----------------------------------------------------
City | SOUTH LYON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48178-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-486-1110
-----------------------------------------------------
Fax | 248-486-3318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 790 REMINGTON BLVD
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-4909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501000577
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251H1200X
-----------------------------------------------------
Taxonomy Name | Hand Physical Therapist
-----------------------------------------------------
License Number | 5501000577
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------