Provider Demographics
NPI:1386620961
Name:ROSCOE, JEREMY WADE (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:WADE
Last Name:ROSCOE
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 1:1516 TREVOR CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-6465
Mailing Address - Country:US
Mailing Address - Phone:317-859-1160
Mailing Address - Fax:
Practice Address - Street 1:401 CAMBY CT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-4085
Practice Address - Country:US
Practice Address - Phone:317-881-8737
Practice Address - Fax:317-881-8735
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1057187208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN371487209OtherTAX ID
IN200479420AMedicaid