Provider Demographics
NPI:1295725380
Name:ROOT, MAX ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:MAX
Middle Name:ROBERT
Last Name:ROOT
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:2825 E MALL DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-1954
Practice Address - Country:US
Practice Address - Phone:435-656-8800
Practice Address - Fax:435-627-1809
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT176571-1205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
E03475Medicare UPIN
UT000055494Medicare ID - Type UnspecifiedMEDICARE GROUP#
UT000010349Medicare ID - Type UnspecifiedMEDICARE IDV. #