MEDICARE: DR. MICHAEL THOMAS ROTHERMICH 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	207Q00000X	Family Medicine Physician	2002011778	MO

General Provider Information

NPI Number	:	1629063524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL THOMAS ROTHERMICH M.D.

Provider Business Mailing Address
First Line	:	PO BOX 19
Second Line	:
City	:	HERMANN
State	:	MO
Zip	:	65041-0019
Country	:	US
Telephone Number	:	573-486-1193
Fax Number	:

Provider Business Practice Location Address
First Line	:	504 N STURGEON ST
Second Line	:
City	:	MONTGOMERY CITY
State	:	MO
Zip	:	63361-1829
Country	:	US
Telephone Number	:	573-564-2990
Fax Number	:

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

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	02/08/2012

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