MEDICARE: BENJAMIN A ROUTH

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	2255A2300X	Athletic Trainer	UJ877679	OH

General Provider Information

NPI Number	:	1659835759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN A ROUTH

Provider Business Mailing Address
First Line	:	7933 DAIRY LN
Second Line	:
City	:	ATHENS
State	:	OH
Zip	:	45701-9392
Country	:	US
Telephone Number	:	614-273-9548
Fax Number	:

Provider Business Practice Location Address
First Line	:	4677 HIRTH HILL RD W
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-4513
Country	:	US
Telephone Number	:	614-273-9548
Fax Number	:

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

Provider Enumeration Date	:	01/23/2019
Last Update Date	:	01/23/2019

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Directions to “ BENJAMIN A ROUTH ” Practice Location

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