=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841237658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO A ROLDAN M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1044 N MOZART ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-2789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-676-5326
-----------------------------------------------------
Fax | 773-276-3179
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4314 W PRATT AVE
-----------------------------------------------------
City | LINCOLNWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60712-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-679-0494
-----------------------------------------------------
Fax | 773-276-3179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 36050636
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 01058156A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------