Basic Information
Provider Information | |||||||||
NPI: | 1982869657 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROTH | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | BRANDON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20744 GEMINI TRL | ||||||||
Address2: |   | ||||||||
City: | LAKEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 550442515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529857099 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1575 BEAM AVE | ||||||||
Address2: | EMERGENCY DEPT | ||||||||
City: | MAPLEWOOD | ||||||||
State: | MN | ||||||||
PostalCode: | 551091126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512327000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2008 | ||||||||
LastUpdateDate: | 02/04/2022 | ||||||||
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 | 207P00000X | 21199 | MN | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 53834 | MN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.