=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477582898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE ANN ROTH RD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 11/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4800 MCLEOD DR E BAY AREA REGIONAL DIALYSIS CTR - CKD SERVICES
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48604-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-790-9440
-----------------------------------------------------
Fax | 989-790-1335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 545 E DAWN DR
-----------------------------------------------------
City | FREELAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48623-9059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-695-5690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133VN1005X
-----------------------------------------------------
Taxonomy Name | Renal Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 14777
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------