Provider Demographics
NPI:1023287695
Name:ROBERT ROTH MD A PROFESSIONAL
Entity type:Organization
Organization Name:ROBERT ROTH MD A PROFESSIONAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLER/CODER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:702-363-5575
Mailing Address - Street 1:2647 BOX CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0450
Mailing Address - Country:US
Mailing Address - Phone:702-363-5575
Mailing Address - Fax:702-646-1727
Practice Address - Street 1:2647 BOX CANYON DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0450
Practice Address - Country:US
Practice Address - Phone:702-363-5575
Practice Address - Fax:702-646-1727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8797261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV101524OtherMEDICARE GROUP #