MEDICARE: DR. MARIO A ROLDAN 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	207V00000X	Obstetrics & Gynecology Physician	36050636	IL
2	207V00000X	Obstetrics & Gynecology Physician	01058156A	IN

General Provider Information

NPI Number	:	1841237658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIO A ROLDAN M.D

Provider Business Mailing Address
First Line	:	4314 W PRATT AVE
Second Line	:
City	:	LINCOLNWOOD
State	:	IL
Zip	:	60712-3535
Country	:	US
Telephone Number	:	847-679-0494
Fax Number	:	773-276-3179

Provider Business Practice Location Address
First Line	:	1044 N MOZART ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2789
Country	:	US
Telephone Number	:	888-676-5326
Fax Number	:	773-276-3179

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	07/09/2007

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