Provider Demographics
NPI:1962487462
Name:NELSON, ROSCOE S (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSCOE
Middle Name:S
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 52004
Mailing Address - Street 2:DEPT. CODE 902
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072
Mailing Address - Country:US
Mailing Address - Phone:602-557-0007
Mailing Address - Fax:602-557-0001
Practice Address - Street 1:6320 W UNION HILLS DR
Practice Address - Street 2:BLDG B SUITE 2600
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1096
Practice Address - Country:US
Practice Address - Phone:602-942-5600
Practice Address - Fax:623-825-6386
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27180208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ467870Medicaid
AZZ184433Medicare PIN
AZG87196Medicare UPIN
AZ340018596Medicare ID - Type UnspecifiedRAILROAD MEDICARE
AZ65588Medicare ID - Type Unspecified
AZ467870002Medicaid