Basic Information
| Provider Information | |||||||||
| NPI: | 1225179872 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEFFREY A ROTHER MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 G ST NW | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734011812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802242900 | ||||||||
| FaxNumber: | 5802240009 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 G ST NW | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734011812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802242900 | ||||||||
| FaxNumber: | 5802240009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | ROTHER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5802242900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 17679 | OK | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100101430A | 05 | OK | MEDICAID |