MEDICARE: DR. MEGHABHUTI ROTH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	29482	MN

General Provider Information

NPI Number	:	1215995071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MEGHABHUTI ROTH M.D.

Provider Business Mailing Address
First Line	:	5178 CENTRAL AVE NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-1825
Country	:	US
Telephone Number	:	763-586-6045
Fax Number	:	763-586-1098

Provider Business Practice Location Address
First Line	:	5178 CENTRAL AVE NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-1825
Country	:	US
Telephone Number	:	763-586-6045
Fax Number	:	763-586-1098

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	09/21/2020

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