Basic Information
| Provider Information | |||||||||
| NPI: | 1972502581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | STAT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1326 EISENHOWER DR | ||||||||
| Address2: | BLDG 2 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123545543 | ||||||||
| FaxNumber: | 9123549365 | ||||||||
| Practice Location | |||||||||
| Address1: | 1326 EISENHOWER DR | ||||||||
| Address2: | BLDG 2 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123545543 | ||||||||
| FaxNumber: | 9123549365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 036446 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 000532441E | 05 | GA | MEDICAID | 454524 | 01 | GA | BCBS | OTHER | G36446 | 05 | SC | MEDICAID | 440003516 | 01 | GA | RR MEDICARE | OTHER |