Provider Demographics
NPI:1750682233
Name:JOHN D ROSCOE MD PC
Entity type:Organization
Organization Name:JOHN D ROSCOE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DOMINIC
Authorized Official - Last Name:ROSCOE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:219-465-7277
Mailing Address - Street 1:2000 ROOSEVELT RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2800
Mailing Address - Country:US
Mailing Address - Phone:219-465-7277
Mailing Address - Fax:219-464-2957
Practice Address - Street 1:2000 ROOSEVELT RD
Practice Address - Street 2:SUITE 203
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2800
Practice Address - Country:US
Practice Address - Phone:219-465-7277
Practice Address - Fax:219-464-2957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030427A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100208460AMedicaid
IN100208460AMedicaid