1487604948 NPI number — MR. TY MARTIN ROSEBERRY PA

Table of content: MR. TY MARTIN ROSEBERRY PA (NPI 1487604948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487604948 NPI number — MR. TY MARTIN ROSEBERRY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSEBERRY
Provider First Name:
TY
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1487604948
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14380 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 120, PMB 160
Provider Business Mailing Address City Name:
HESPERIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92345-4613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-947-3220
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 N SENATE BLVD
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-1228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-802-2000
Provider Business Practice Location Address Fax Number:
317-924-0115
Provider Enumeration Date:
05/12/2006

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: 363A00000X , with the licence number:  10000768A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 19182 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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