Provider Demographics
NPI:1346604303
Name:ROSKOVENSKY, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ROSKOVENSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 W CLARK RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1120
Mailing Address - Country:US
Mailing Address - Phone:734-528-9760
Mailing Address - Fax:734-528-9761
Practice Address - Street 1:2577 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3818
Practice Address - Country:US
Practice Address - Phone:734-929-6400
Practice Address - Fax:734-929-6401
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015942225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist