Provider Demographics
NPI:1770893091
Name:ROSEVILLE MEDICAL GROUP PA
Entity type:Organization
Organization Name:ROSEVILLE MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:RAOUF
Authorized Official - Middle Name:KAMEL
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-482-7245
Mailing Address - Street 1:18 ALICIA CT
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1901
Mailing Address - Country:US
Mailing Address - Phone:973-857-1560
Mailing Address - Fax:
Practice Address - Street 1:346 ROSEVILLE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1722
Practice Address - Country:US
Practice Address - Phone:973-482-7245
Practice Address - Fax:973-482-0274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA30602173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ452156Medicare UPIN