Provider Demographics
NPI:1427085885
Name:ROSELLI, NICOLA (NICK) (OTRCHT)
Entity type:Individual
Prefix:MR
First Name:NICOLA (NICK)
Middle Name:
Last Name:ROSELLI
Suffix:
Gender:M
Credentials:OTRCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5847 FRANCIS LEWIS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GDNS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1601
Mailing Address - Country:US
Mailing Address - Phone:718-454-0842
Mailing Address - Fax:718-454-1704
Practice Address - Street 1:5847 FRANCIS LEWIS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:OAKLAND GDNS
Practice Address - State:NY
Practice Address - Zip Code:11364-1601
Practice Address - Country:US
Practice Address - Phone:718-454-0842
Practice Address - Fax:718-454-1704
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005312-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113231115OtherUNITEDHEALTHCARE
NY5054447OtherCIGNA
NYP439298OtherOXFORD
NY817707OtherMPN
NY139263POtherHIP
NY02247Medicare ID - Type UnspecifiedGHI MEDICARE