Provider Demographics
NPI:1245497478
Name:ROLLS, JASON ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANDREW
Last Name:ROLLS
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 1:4160 JOHN R ST
Mailing Address - Street 2:SUITE 615
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2020
Mailing Address - Country:US
Mailing Address - Phone:313-745-4195
Mailing Address - Fax:313-993-8669
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:SUITE 615
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-745-4195
Practice Address - Fax:313-993-8669
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301099790204F00000X, 208600000X
NC2009-02112208600000X
NY219786208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245497478Medicaid
MIMI3973490Medicare PIN
NC5913567Medicaid