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General NPI Number Information
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NPI Number | 1003139031
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Entity Type | Organization
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Legal Business Name | ROSELLE PODIATRY GROUP, PA
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Dates
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Enumeration Date | 03/04/2010
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Last Update Date | 10/16/2014
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Provider Practice Location Address
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Address Line | 776 E 3RD AVE
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City | ROSELLE
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State | NJ
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Zip | 07203-1698
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Country | US
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Telephone | 908-620-3200
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Fax | 908-620-1040
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Provider Business Mailing Address
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Address Line | 776 E 3RD AVE
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City | ROSELLE
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State | NJ
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Zip | 07203-1698
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Country | US
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Telephone | 908-620-3200
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Fax | 908-620-1040
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Authorized Official
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Title or Position | PRESIDENT
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Name | YEON SHIM
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Credential | DPM
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Telephone | 908-620-3200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | MD002426
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License Number State | NJ
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