Provider Demographics
NPI:1700034592
Name:ROESCH, BENNO GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNO
Middle Name:GEORGE
Last Name:ROESCH
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 1:581 FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:ORADELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07649-2501
Mailing Address - Country:US
Mailing Address - Phone:201-265-1842
Mailing Address - Fax:
Practice Address - Street 1:241 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5715
Practice Address - Country:US
Practice Address - Phone:201-678-0288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07669900208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE23617Medicare UPIN