Provider Demographics
NPI:1891914602
Name:ROGER W. NUTT, M.D.,P.C.
Entity Type:Organization
Organization Name:ROGER W. NUTT, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:NUTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-344-4907
Mailing Address - Street 1:710 S 13TH ST
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-5792
Mailing Address - Country:US
Mailing Address - Phone:402-370-4570
Mailing Address - Fax:
Practice Address - Street 1:710 S 13TH ST
Practice Address - Street 2:SUITE 1200
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-5792
Practice Address - Country:US
Practice Address - Phone:402-370-4570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15072261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ251778Medicaid
AZD25507Medicare UPIN
AZ22287Medicare ID - Type Unspecified