Provider Demographics
NPI:1447445291
Name:SCOTT L. ROTH M.D, LLC
Entity type:Organization
Organization Name:SCOTT L. ROTH M.D, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-426-4160
Mailing Address - Street 1:1012 ELMGROVE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1324
Mailing Address - Country:US
Mailing Address - Phone:585-426-4160
Mailing Address - Fax:585-426-4167
Practice Address - Street 1:1012 ELMGROVE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1324
Practice Address - Country:US
Practice Address - Phone:585-426-4160
Practice Address - Fax:585-426-4167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150586261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01449238Medicaid
NY01449238Medicaid
NYBB9403Medicare PIN