Provider Demographics
NPI:1528007929
Name:ROOSEVELT SURGICAL ASSOCIATES,INC.
Entity Type:Organization
Organization Name:ROOSEVELT SURGICAL ASSOCIATES,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-424-0941
Mailing Address - Street 1:4040 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-6619
Mailing Address - Country:US
Mailing Address - Phone:513-424-0941
Mailing Address - Fax:513-424-9758
Practice Address - Street 1:4040 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-6619
Practice Address - Country:US
Practice Address - Phone:513-424-0941
Practice Address - Fax:513-424-9758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0973138Medicaid
OHRO9268751Medicare ID - Type UnspecifiedMEDICARE ID NUMBER