MEDICARE: MR. RICHARD STAT ROTH MD

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	207RI0200X	Infectious Disease Physician	036446	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	440003516	OTHER	GA	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	454524	OTHER	GA	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972502581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD STAT ROTH MD

Provider Business Mailing Address
First Line	:	100 EDDIE JUNGEMANN DRIVE, SUITE B
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31408
Country	:	US
Telephone Number	:	912-354-5543
Fax Number	:	912-354-9365

Provider Business Practice Location Address
First Line	:	100 EDDIE JUNGEMANN DRIVE, SUITE B
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31408
Country	:	US
Telephone Number	:	912-964-7684
Fax Number	:	912-354-9365

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	02/28/2023

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