Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | 3820 | MT |
NPI | 1043233877 |
---|---|
Provider Name | George C Roth JR. |
First Address | Missoula, MT 59804-7419 |
Second Address | Missoula, MT 59804-7419 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0000019074 | (05) | MT |
D96042 | (02) |