Healthcare Provider Details

I. General information

NPI: 1063966778
Provider Name (Legal Business Name): ROSHAN K MATHEW, MD. P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 FAIRVIEW DR
OWENSBORO KY
42303-2175
US

IV. Provider business mailing address

2609 NEW HARTFORD RD
OWENSBORO KY
42303-1316
US

V. Phone/Fax

Practice location:
  • Phone: 270-240-2129
  • Fax: 270-240-1227
Mailing address:
  • Phone: 270-240-1747
  • Fax: 270-240-1748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number39846
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number39846
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELSEY HAYS
Title or Position: BILLING MANAGER/AUTHORIZED OFFICIAL
Credential:
Phone: 270-240-2129