MEDICARE: MORRIS MEDICAL CENTER, LTD.

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	207VG0400X	Gynecology Physician		IL

General Provider Information

NPI Number	:	1699951293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORRIS MEDICAL CENTER, LTD.

Provider Business Mailing Address
First Line	:	107 W JEFFERSON ST
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-2128
Country	:	US
Telephone Number	:	815-942-0683
Fax Number	:	815-942-5624

Provider Business Practice Location Address
First Line	:	107 W JEFFERSON ST
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-2128
Country	:	US
Telephone Number	:	815-942-0683
Fax Number	:	815-942-5624

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN B. ROTH JR.
Credential	:	M.D.
Telephone Number	:	815-942-0683

Provider Enumeration Date	:	01/14/2008
Last Update Date	:	01/14/2008

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