Healthcare Provider Details

I. General information

NPI: 1710953203
Provider Name (Legal Business Name): PAUL HOWELL ROLSTON , M.M.SC., P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTHEASTERN HOSPITAL 2186 ALLEGHENY ROAD
PHILADELPHIA PA
19114-1436
US

IV. Provider business mailing address

2201 PENNSYLVANIA AVE APT # 803
PHILADELPHIA PA
19130-3513
US

V. Phone/Fax

Practice location:
  • Phone: 215-291-3620
  • Fax:
Mailing address:
  • Phone: 215-587-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA052239
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: