Provider Demographics
NPI:1235296526
Name:SHANNON ROESCH, DPM PC
Entity Type:Organization
Organization Name:SHANNON ROESCH, DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROESCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-488-6290
Mailing Address - Street 1:242 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-2147
Mailing Address - Country:US
Mailing Address - Phone:516-488-6290
Mailing Address - Fax:516-488-3172
Practice Address - Street 1:242 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-2147
Practice Address - Country:US
Practice Address - Phone:516-488-6290
Practice Address - Fax:516-488-3172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005991213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1779083OtherCIGNA
NY7444873OtherAETNA
NY00599165NYOther1199
NY0151722OtherGHI
NYN005991OtherHIP
NYP3722100OtherOXFORD
NY6C1150OtherHEALTHNET
NYPL2751OtherBLUE CROSS BLUE SHIELD
NYP3722100OtherOXFORD
NYPJ7042Medicare ID - Type UnspecifiedEMPIRE MEDICARE
NY00599165NYOther1199
NY6C1150OtherHEALTHNET
NYV03141Medicare UPIN