MEDICARE: JACKIE A ROSARIO-PIRTLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1457925349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE A ROSARIO-PIRTLE

Provider Business Mailing Address
First Line	:	1520 WALLACE ST
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46404-1865
Country	:	US
Telephone Number	:	219-670-5438
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 E 86TH CT STE 205
Second Line	:
City	:	MERRILLVILLE
State	:	IN
Zip	:	46410-6259
Country	:	US
Telephone Number	:	219-670-5438
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2021
Last Update Date	:	05/17/2021

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