Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | LP2737 | MN |
Y | 103T00000X | Psychologist | LP2737 | MN |
NPI | 1003037490 |
---|---|
Provider Name | Dr. Lloyd E Rootes |
First Address | Bemidji, MN 56601-3010 |
Second Address | Bemidji, MN 56601-3010 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
163M9RO | BLUE CROSS BLUE SHIELD MN (01) | MN |