Provider Demographics
NPI:1639394034
Name:ROSCOE, BRANDON M (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:M
Last Name:ROSCOE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 BEAVER DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2434
Mailing Address - Country:US
Mailing Address - Phone:814-503-8070
Mailing Address - Fax:814-503-8531
Practice Address - Street 1:33 BEAVER DR
Practice Address - Street 2:SUITE 1
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2434
Practice Address - Country:US
Practice Address - Phone:814-503-8070
Practice Address - Fax:814-503-8531
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52046207Q00000X
PAMD442231207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1639394034Medicaid
MN080018333Medicare PIN