Basic Information
| Provider Information | |||||||||
| NPI: | 1952309213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTHMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | IAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 23625 COMMERCE PARK | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555700 | ||||||||
| FaxNumber: | 2162555701 | ||||||||
| Practice Location | |||||||||
| Address1: | 870 WAFFORD LANE | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180173876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555700 | ||||||||
| FaxNumber: | 2162555701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 03/22/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036078872 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | D0036911 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD039205E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | MD039205E | 01 | PA | LICENSE | OTHER | 0017172610016 | 05 | PA | MEDICAID | 021449XRE | 01 | PENNSYLVANIA MEDICARE | OTHER | 043597 | 01 | CT | LICENSE | OTHER | 881901 | 01 | PA | HIGHMARK | OTHER | 1012411910001 | 05 | PA | MEDICAID | 8962103 | 05 | NJ | MEDICAID | C1-0007404 | 01 | DE | LICENSE | OTHER | 239105-1 | 01 | NY | LICENSE | OTHER | 25MA08035800 | 01 | NJ | LICENSE | OTHER | 02906701 | 05 | NY | MEDICAID | BR1924009 | 01 | DEA | OTHER | D003691 | 01 | MD | LICENSE | OTHER |