MEDICARE: MARK L ROA MA, LP

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	103T00000X	Psychologist	LP3689	MN

General Provider Information

NPI Number	:	1275597957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK L ROA MA, LP

Provider Business Mailing Address
First Line	:	PO BOX 43
Second Line	:	MR 10809
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55440-0043
Country	:	US
Telephone Number	:	612-262-4813
Fax Number	:	612-262-4194

Provider Business Practice Location Address
First Line	:	2545 CHICAGO AVE
Second Line	:	SUITE 701
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4522
Country	:	US
Telephone Number	:	612-863-5327
Fax Number	:	612-863-2596

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

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	07/08/2007

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