Healthcare Provider Details

I. General information

NPI: 1902254634
Provider Name (Legal Business Name): GREGORY ROSCOE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 BEAVER AVE
PITTSBURGH PA
15233-2342
US

IV. Provider business mailing address

1301 BEAVER AVE
PITTSBURGH PA
15233-2342
US

V. Phone/Fax

Practice location:
  • Phone: 412-478-6736
  • Fax:
Mailing address:
  • Phone: 412-478-6736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: