Healthcare Provider Details

I. General information

NPI: 1669586582
Provider Name (Legal Business Name): MICHAEL ROLLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 06/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SHAPE HCF UNIT 21414 BOX 153
APO AE
09705
US

IV. Provider business mailing address

SHAPE HCF UNIT 21414 BOX 153
APO AE
09705
US

V. Phone/Fax

Practice location:
  • Phone: 0113265443321
  • Fax: 0113265445882
Mailing address:
  • Phone: 003265443321
  • Fax: 03265445882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD0000048561
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: