Healthcare Provider Details

I. General information

NPI: 1871788877
Provider Name (Legal Business Name): ROSEDALE MEDICAL OFFICE,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25302 147TH AVE
ROSEDALE NY
11422-2541
US

IV. Provider business mailing address

25302 147TH AVE
ROSEDALE NY
11422-2541
US

V. Phone/Fax

Practice location:
  • Phone: 718-341-3535
  • Fax: 718-341-1730
Mailing address:
  • Phone: 718-341-3535
  • Fax: 718-341-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number171192
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number171192
License Number StateNY

VIII. Authorized Official

Name: WILLIAM AKWASI ANKOBIAH
Title or Position: CEO
Credential: M.D.
Phone: 719-341-3535