MEDICARE: DR. JOE ROTH NIELSEN 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	174400000X	Specialist	178171-1205	UT

General Provider Information

NPI Number	:	1992766885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOE ROTH NIELSEN M.D.

Provider Business Mailing Address
First Line	:	415 MEDICAL DR
Second Line	:	#D-200
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-4946
Country	:	US
Telephone Number	:	801-292-6277
Fax Number	:	801-292-1108

Provider Business Practice Location Address
First Line	:	415 MEDICAL DR
Second Line	:	#D-200
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-4946
Country	:	US
Telephone Number	:	801-292-6277
Fax Number	:	801-292-1108

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

Provider Enumeration Date	:	03/30/2006
Last Update Date	:	08/10/2010

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