Basic Information
| Provider Information | |||||||||
| NPI: | 1962487462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | ROSCOE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52004 | ||||||||
| Address2: | DEPT. CODE 902 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025570007 | ||||||||
| FaxNumber: | 6025570001 | ||||||||
| Practice Location | |||||||||
| Address1: | 6320 W UNION HILLS DR | ||||||||
| Address2: | BLDG B SUITE 2600 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853081096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029425600 | ||||||||
| FaxNumber: | 6238256386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 27180 | AZ | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 467870 | 05 | AZ | MEDICAID |