MEDICARE: DR. MARC CHAGALL ROTHGERY M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1366677874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARC CHAGALL ROTHGERY M.D.

Provider Business Mailing Address
First Line	:	1223 E 600 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-3202
Country	:	US
Telephone Number	:	518-258-6881
Fax Number	:

Provider Business Practice Location Address
First Line	:	1223 E 600 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-3202
Country	:	US
Telephone Number	:	518-258-6881
Fax Number	:

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

Provider Enumeration Date	:	05/28/2009
Last Update Date	:	05/28/2009

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