Provider Demographics
NPI:1861278970
Name:ROSCOE, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:ROSCOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15374 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-1519
Mailing Address - Country:US
Mailing Address - Phone:313-686-9845
Mailing Address - Fax:
Practice Address - Street 1:15374 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1519
Practice Address - Country:US
Practice Address - Phone:313-686-9845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker