Provider Demographics
NPI:1063966778
Name:ROSHAN K MATHEW, MD. P.S.C.
Entity type:Organization
Organization Name:ROSHAN K MATHEW, MD. P.S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-240-2129
Mailing Address - Street 1:2609 NEW HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1316
Mailing Address - Country:US
Mailing Address - Phone:270-240-1747
Mailing Address - Fax:270-240-1748
Practice Address - Street 1:3110 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-2175
Practice Address - Country:US
Practice Address - Phone:270-240-2129
Practice Address - Fax:270-240-1227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-10
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39846207RI0011X, 207RC0000X
363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty