Healthcare Provider Details

I. General information

NPI: 1073621918
Provider Name (Legal Business Name): MIKHAIL ROSHAL M.D, PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

633 3RD AVE
NEW YORK NY
10017-6706
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number60257092
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number06257092
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: