Provider Demographics
NPI:1124109335
Name:ROSCOE, GREGORY JAMES (DMD, MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES
Last Name:ROSCOE
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 BEAVER DRIVE
Mailing Address - Street 2:PO BOX 308
Mailing Address - City:DUBOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-0308
Mailing Address - Country:US
Mailing Address - Phone:814-375-0455
Mailing Address - Fax:814-375-2721
Practice Address - Street 1:871 BEAVER DR
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2511
Practice Address - Country:US
Practice Address - Phone:814-375-0455
Practice Address - Fax:814-375-2721
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038440L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA040000667OtherRAILROAD MEDICARE, PIN
PA0008776540004Medicaid
PA161530OtherHIGHMARK BLUE SHIELD
PA161530MT4Medicare PIN
PA040000667OtherRAILROAD MEDICARE, PIN