Provider Demographics
NPI:1003139031
Name:ROSELLE PODIATRY GROUP, PA
Entity Type:Organization
Organization Name:ROSELLE PODIATRY GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YEON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:908-620-3200
Mailing Address - Street 1:776 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-1698
Mailing Address - Country:US
Mailing Address - Phone:908-620-3200
Mailing Address - Fax:908-620-1040
Practice Address - Street 1:776 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203-1698
Practice Address - Country:US
Practice Address - Phone:908-620-3200
Practice Address - Fax:908-620-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD002426213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4702770001OtherMEDICARE DME
NJ4702770001OtherMEDICARE DME
4702770001Medicare NSC