MEDICARE: ROGER WILLIAMS MD PC

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	207Q00000X	Family Medicine Physician	22260	AZ

General Provider Information

NPI Number	:	1972783736
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROGER WILLIAMS MD PC

Provider Business Mailing Address
First Line	:	PO BOX 10
Second Line	:
City	:	OVERGAARD
State	:	AZ
Zip	:	85933-0010
Country	:	US
Telephone Number	:	928-535-6667
Fax Number	:	928-535-5561

Provider Business Practice Location Address
First Line	:	5448 WHITE MOUNTAIN BLVD
Second Line	:	SUITE 270
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5739
Country	:	US
Telephone Number	:	928-532-5838
Fax Number	:	928-532-6670

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROGER T WILLIAMS
Credential	:	MD
Telephone Number	:	928-532-5838

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	12/12/2008

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