Basic Information
| Provider Information | |||||||||
| NPI: | 1578657383 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEN ROTH MD & ROLF EHLERS MD SAN DIEGO INTERNAL MEDICINE ASSOC | ||||||||
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| OtherOrganizationName: | SAN DIEGO INTERNAL MEDICINE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8765 AERO DRIVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585410181 | ||||||||
| FaxNumber: | 8586379035 | ||||||||
| Practice Location | |||||||||
| Address1: | 8765 AERO DRIVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585410181 | ||||||||
| FaxNumber: | 8586379035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROTH | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8585410181 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | W12070 | 01 | CA | MEDICARE | OTHER |