Basic Information
| Provider Information | |||||||||
| NPI: | 1245497478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLLS | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4160 JOHN R ST | ||||||||
| Address2: | SUITE 615 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454195 | ||||||||
| FaxNumber: | 3139938669 | ||||||||
| Practice Location | |||||||||
| Address1: | 4160 JOHN R ST | ||||||||
| Address2: | SUITE 615 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454195 | ||||||||
| FaxNumber: | 3139938669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204F00000X | 4301099790 | MI | N | Allopathic & Osteopathic Physicians | Transplant Surgery | 208600000X | 4301099790 | MI | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1245497478 | 05 | MI | MEDICAID |