Basic Information
| Provider Information | |||||||||
| NPI: | 1144210279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 785 5TH AVENUE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7172174217 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 ROADSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172682542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177627155 | ||||||||
| FaxNumber: | 7177626929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 03/08/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD060014L | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 25-1716306 | 01 | PA | MULTIPLAN/PHCS | OTHER | 546216-01 | 01 | MD | MD BLUE SHIELD | OTHER | 367632 | 01 | PA | MAMSI | OTHER | 6720367 | 01 | PA | AETNA HMO | OTHER | 867633 | 01 | PA | MEDICARE GROUP # | OTHER | P00700657 | 01 | PA | RAILROAD MEDICARE | OTHER | 02195701 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 25-1716306 | 01 | PA | INFORMED | OTHER | 25-1716306 | 01 | PA | DEVON | OTHER | 25-1716306 | 01 | PA | HEALTHNET/TRICARE | OTHER | 990003822 | 01 | PA | MEDICARE RAILROAD RETIRE | OTHER | 1007307260034 | 01 | PA | MEDICAID GROUP # | OTHER | 25-1716306 | 01 | PA | GREATWEST HEALTHCARE | OTHER | 5234477 | 01 | PA | AETNA HMO | OTHER | 25-1716306 | 01 | PA | SOUTH CENTRAL PREFERRED | OTHER | 257729 | 01 | PA | UNISON | OTHER | 908528 | 01 | PA | HIGHMARK BLUESHIELD | OTHER | G920-0109/233CCU | 01 | PA | CAREFIRST | OTHER | MD060014L | 01 | PA | LICENSE | OTHER | 0016462400002 | 05 | PA | MEDICAID | 1561881 | 01 | PA | GATEWAY | OTHER | BR5295109 | 01 | PA | DEA | OTHER | 120420403 | 01 | PA | DEPT OF LABOR | OTHER | 25-1716306 | 01 | PA | FIRST HEALTH | OTHER | 267632 | 01 | MD | MAMSI OP CHOICE | OTHER | 25-1716306 | 01 | PA | HEALTH AMERICA | OTHER | 25-1716306 | 01 | PA | INTERGROUP | OTHER | 5234477 | 01 | PA | AETNA NON-HMO | OTHER | 810688 | 01 | PA | AETNA PPO | OTHER |