MEDICARE: DR. RICHARD LEE ROTH M.D.

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	2084P0800X	Psychiatry Physician	0101028447	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8555	OTHER	VA	CAREFILRST BC BS
2	059999	OTHER	VA	ANTHEM BC BS
3	215112	OTHER	VA	MAMSI
4	215112	OTHER	VA	ALLIANCE

General Provider Information

NPI Number	:	1497758098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD LEE ROTH M.D.

Provider Business Mailing Address
First Line	:	6845 ELM ST
Second Line	:	STE 210
City	:	MC LEAN
State	:	VA
Zip	:	22101-3822
Country	:	US
Telephone Number	:	703-821-2337
Fax Number	:

Provider Business Practice Location Address
First Line	:	6845 ELM ST
Second Line	:	STE 210
City	:	MC LEAN
State	:	VA
Zip	:	22101-3822
Country	:	US
Telephone Number	:	703-821-2337
Fax Number	:

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	10/01/2008

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