1295909174 NPI number — DR. GREGORY DANTE ROULETTE MD

Table of content: DR. GREGORY DANTE ROULETTE MD (NPI 1295909174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295909174 NPI number — DR. GREGORY DANTE ROULETTE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROULETTE
Provider First Name:
GREGORY
Provider Middle Name:
DANTE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295909174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 E MARKET ST
Provider Second Line Business Mailing Address:
MEDICAL BUILDING, 2ND FLOOR
Provider Business Mailing Address City Name:
AKRON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44304-1619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-375-6114
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 UNIVERSITY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST CHESTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45069-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-475-8248
Provider Business Practice Location Address Fax Number:
513-475-8468
Provider Enumeration Date:
04/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  MD440660 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VG0400X , with the licence number: 35.122055 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 35.122055 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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