Provider Demographics
NPI:1063671386
Name:ROXANNE FISCELLA, M.D.
Entity Type:Organization
Organization Name:ROXANNE FISCELLA, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:CLAIRE
Authorized Official - Last Name:FISCELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-843-0692
Mailing Address - Street 1:2500 MILVIA ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2636
Mailing Address - Country:US
Mailing Address - Phone:510-843-0692
Mailing Address - Fax:510-843-3230
Practice Address - Street 1:2500 MILVIA ST
Practice Address - Street 2:SUITE 116
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2636
Practice Address - Country:US
Practice Address - Phone:510-843-0692
Practice Address - Fax:510-843-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42958173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G429580Medicare PIN
A49174Medicare UPIN