Provider Demographics
NPI:1003111410
Name:KENNETH T ROOST MD INC
Entity type:Organization
Organization Name:KENNETH T ROOST MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:ROOST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-697-9146
Mailing Address - Street 1:1828 EL CAMINO REAL
Mailing Address - Street 2:#604
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3103
Mailing Address - Country:US
Mailing Address - Phone:650-697-9146
Mailing Address - Fax:
Practice Address - Street 1:1828 EL CAMINO REAL
Practice Address - Street 2:#604
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3103
Practice Address - Country:US
Practice Address - Phone:650-697-9146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27727207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43465Medicare UPIN