MEDICARE: JANE ANN ROTH RD

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	133VN1005X	Renal Nutrition Registered Dietitian	14777	IL

General Provider Information

NPI Number	:	1477582898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE ANN ROTH RD

Provider Business Mailing Address
First Line	:	545 E DAWN DR
Second Line	:
City	:	FREELAND
State	:	MI
Zip	:	48623-9059
Country	:	US
Telephone Number	:	989-695-5690
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 MCLEOD DR E
Second Line	:	BAY AREA REGIONAL DIALYSIS CTR - CKD SERVICES
City	:	SAGINAW
State	:	MI
Zip	:	48604-2839
Country	:	US
Telephone Number	:	989-790-9440
Fax Number	:	989-790-1335

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	11/27/2007

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