MEDICARE: ROGER DALE HAZELBAKER MD

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	ME41254	FL

General Provider Information

NPI Number	:	1871558767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER DALE HAZELBAKER MD

Provider Business Mailing Address
First Line	:	5767 49 STREET NORTH
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709
Country	:	US
Telephone Number	:	727-522-0558
Fax Number	:	727-521-3605

Provider Business Practice Location Address
First Line	:	1417 S BELCHER RD
Second Line	:	#C
City	:	CLEARWATER
State	:	FL
Zip	:	33764
Country	:	US
Telephone Number	:	727-535-0741
Fax Number	:	757-531-8171

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	07/08/2007

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