Healthcare Provider Details

I. General information

NPI: 1497099857
Provider Name (Legal Business Name): RENEE ROLSTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2012
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

525 E 68TH ST
NEW YORK NY
10065-4870
US

V. Phone/Fax

Practice location:
  • Phone: 646-962-5913
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35.146043
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number280537
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: