MEDICARE: KELLY ANN ROTH CPO

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	222Z00000X	Orthotist	213000351	IL
2	224P00000X	Prosthetist	211000319	IL

General Provider Information

NPI Number	:	1790209864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANN ROTH CPO

Provider Business Mailing Address
First Line	:	1450 E JOLIET ST STE 206
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-4726
Country	:	US
Telephone Number	:	219-801-3937
Fax Number	:	219-301-8734

Provider Business Practice Location Address
First Line	:	1450 E JOLIET ST STE 206
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-4726
Country	:	US
Telephone Number	:	219-801-3937
Fax Number	:	219-301-8734

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

Provider Enumeration Date	:	08/01/2017
Last Update Date	:	07/25/2023

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