MEDICARE: DR. STACY DANA ROSKIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME74069	FL
2	207Q00000X	Family Medicine Physician	ME74069	FL

General Provider Information

NPI Number	:	1669530218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY DANA ROSKIN M.D.

Provider Business Mailing Address
First Line	:	3225 NE 167TH ST
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33160-3847
Country	:	US
Telephone Number	:	786-480-5705
Fax Number	:

Provider Business Practice Location Address
First Line	:	3435 NE 163RD ST
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33160-4426
Country	:	US
Telephone Number	:	786-480-5707
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	10/13/2020

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