Basic Information
| Provider Information | |||||||||
| NPI: | 1932102985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTHSTEIN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | TERRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 FRANTZ RD STE 360 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145446155 | ||||||||
| FaxNumber: | 6145446370 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 HOSPITAL DR | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457012857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405924491 | ||||||||
| FaxNumber: | 7405924844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 12/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/24/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD011535 | HI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35-037876 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0259134 | 05 | OH | MEDICAID | RO0408502 | 01 | MEDICARE PROVIDER NUMBER | OTHER |