MEDICARE: DR. JOSEPH C. ROTH DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5101008288	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1124120597	OTHER		NPI
2	371573958	OTHER	MI	TAX ID

General Provider Information

NPI Number	:	1124120597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH C. ROTH DO

Provider Business Mailing Address
First Line	:	11320 S. M 43 HWY.
Second Line	:
City	:	DELTON
State	:	MI
Zip	:	49046-9259
Country	:	US
Telephone Number	:	269-623-5521
Fax Number	:

Provider Business Practice Location Address
First Line	:	11320 S. M 43 HWY
Second Line	:
City	:	DELTON
State	:	MI
Zip	:	49046-9259
Country	:	US
Telephone Number	:	269-623-5121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	11/19/2011

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Directions to “ DR. JOSEPH C. ROTH DO” Practice Location

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