MEDICARE: MARY ROTH

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	163WC1500X	Community Health Registered Nurse	201042572RN	OR

General Provider Information

NPI Number	:	1447011143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ROTH

Provider Business Mailing Address
First Line	:	705 HOWARD ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-3026
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 HOWARD ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-3026
Country	:	US
Telephone Number	:	971-332-0316
Fax Number	:

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

Provider Enumeration Date	:	01/19/2024
Last Update Date	:	01/19/2024

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Directions to “ MARY ROTH ” Practice Location

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