Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5501000577 | MI |
N | 2251H1200X | Hand | 5501000577 | MI |
NPI | 1497747323 |
---|---|
Provider Name | Christian William Roth |
First Address | Bolingbrook, IL 60440-4909 |
Second Address | South Lyon, MI 48178-1407 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2005 |
Last Update Date | 11/11/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0H71069 | BCBSMI (01) | MI |
4709236 | (05) | MI |