=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851407860
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL LEWIS ROTH M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 665 WINTER ST SE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-561-5356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7897 LAVENDER LN SE
-----------------------------------------------------
City | TURNER
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97392-9361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-375-6403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | OR MD 17900
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------