Provider Demographics
NPI:1487688453
Name:ROESER, MINDI M (MD)
Entity Type:Individual
Prefix:
First Name:MINDI
Middle Name:M
Last Name:ROESER
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 1:800 SPRUCE STREET
Mailing Address - Street 2:PINE 1 WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6130
Mailing Address - Country:US
Mailing Address - Phone:215-829-7817
Mailing Address - Fax:251-829-7129
Practice Address - Street 1:800 SPRUCE STREET
Practice Address - Street 2:PINE 1 WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6130
Practice Address - Country:US
Practice Address - Phone:215-829-7817
Practice Address - Fax:215-829-7129
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD048483L207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001411940Medicaid
PA746699Medicare PIN
PA001411940Medicaid