=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235296526
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHANNON ROESCH, DPM PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 12/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 242 JERICHO TPKE
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-488-6290
-----------------------------------------------------
Fax | 516-488-3172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 242 JERICHO TPKE
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-488-6290
-----------------------------------------------------
Fax | 516-488-3172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR
-----------------------------------------------------
Name | SHANNON ROESCH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 516-488-6290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | N005991
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------