Provider Demographics
NPI:1477582898
Name:ROTH, JANE ANN (RD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ANN
Last Name:ROTH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:ANN
Other - Last Name:MROZINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:545 E DAWN DR
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-9059
Mailing Address - Country:US
Mailing Address - Phone:989-695-5690
Mailing Address - Fax:
Practice Address - Street 1:4800 MCLEOD DR E
Practice Address - Street 2:BAY AREA REGIONAL DIALYSIS CTR - CKD SERVICES
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2839
Practice Address - Country:US
Practice Address - Phone:989-790-9440
Practice Address - Fax:989-790-1335
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14777133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N95940Medicare UPIN