Provider Demographics
NPI:1649420258
Name:GWEN ROESEL MD LLC
Entity Type:Organization
Organization Name:GWEN ROESEL MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROESEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-271-2862
Mailing Address - Street 1:9435 WATERSTONE BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45249-8226
Mailing Address - Country:US
Mailing Address - Phone:513-271-2862
Mailing Address - Fax:513-271-0619
Practice Address - Street 1:9435 WATERSTONE BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-8226
Practice Address - Country:US
Practice Address - Phone:513-271-2862
Practice Address - Fax:513-271-0619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.090806261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGW9380231Medicare PIN