Healthcare Provider Details

I. General information

NPI: 1386620961
Provider Name (Legal Business Name): JEREMY WADE ROSCOE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CAMBY CT
GREENWOOD IN
46142-4085
US

IV. Provider business mailing address

1516 TREVOR CT
GREENWOOD IN
46143-6465
US

V. Phone/Fax

Practice location:
  • Phone: 317-881-8737
  • Fax: 317-881-8735
Mailing address:
  • Phone: 317-859-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1057187
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: