Provider Demographics
NPI:1235113770
Name:ROSKOS, INGRID K (MD)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:K
Last Name:ROSKOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 ROBERT BLVD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2004
Mailing Address - Country:US
Mailing Address - Phone:985-781-4848
Mailing Address - Fax:985-781-4850
Practice Address - Street 1:1150 ROBERT BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2004
Practice Address - Country:US
Practice Address - Phone:985-781-4848
Practice Address - Fax:985-781-4850
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14651R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1128767Medicaid
LA1128767Medicaid
MS$$$$$$$$$OtherBCBS OF MS PROVIDER NUMBER
H64133Medicare UPIN
LA$$$$$$$$$0OtherBCBS OF LA PROVIDER NUMBER
MS$$$$$$$$$OtherBCBS OF MS PROVIDER NUMBER