MEDICARE: SHANNON ROESCH DPM PC

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	213ES0103X	Foot & Ankle Surgery Podiatrist	N005991	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00599165NY	OTHER	NY	1199
2	6C1150	OTHER	NY	HEALTHNET
3	0151722	OTHER	NY	GHI
4	1779083	OTHER	NY	CIGNA
5	7444873	OTHER		AETNA
6	P3722100	OTHER	NY	OXFORD
7	N005991	OTHER	NY	HIP
8	PL2751	OTHER	NY	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1992876239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON ROESCH DPM PC

Provider Business Mailing Address
First Line	:	242 JERICHO TPKE
Second Line	:
City	:	FLORAL PARK
State	:	NY
Zip	:	11001-2147
Country	:	US
Telephone Number	:	516-488-6290
Fax Number	:	516-488-3172

Provider Business Practice Location Address
First Line	:	242 JERICHO TPKE
Second Line	:
City	:	FLORAL PARK
State	:	NY
Zip	:	11001-2147
Country	:	US
Telephone Number	:	516-488-6290
Fax Number	:	516-488-3172

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

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	12/30/2019

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Directions to “ SHANNON ROESCH DPM PC” Practice Location

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