1306155874 NPI number — ROSEHOUSE SURGICARE

Table of content: (NPI 1306155874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306155874 NPI number — ROSEHOUSE SURGICARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSEHOUSE SURGICARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OMNICARE PLUS
Provider Other Organization Name Type Code:
3
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:
1306155874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O.BOX 30037
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMONT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11003-0037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-433-0044
Provider Business Mailing Address Fax Number:
718-400-4644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1975 LINDEN BLVD STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMONT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11003-4004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-433-4644
Provider Business Practice Location Address Fax Number:
718-433-4644
Provider Enumeration Date:
10/01/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CREVECOEUR
Authorized Official First Name:
EVANS
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/CEO
Authorized Official Telephone Number:
718-433-0044

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 1777953-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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