Healthcare Provider Details

I. General information

NPI: 1033508742
Provider Name (Legal Business Name): ROXBOROUGH MEDICAL NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 03/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5735 RIDGE AVE SUITE 106
PHILADELPHIA PA
19128-1745
US

IV. Provider business mailing address

5735 RIDGE AVE SUITE 106
PHILADELPHIA PA
19128-1745
US

V. Phone/Fax

Practice location:
  • Phone: 570-366-4606
  • Fax: 570-366-5032
Mailing address:
  • Phone: 570-366-4606
  • Fax: 570-366-5032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURIE FENSTERMACHER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 570-366-4606