1598084667 NPI number — SHANNON MARIE ROSKAMP PT, DPT, MSA

Table of content: (NPI 1679892897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598084667 NPI number — SHANNON MARIE ROSKAMP PT, DPT, MSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSKAMP
Provider First Name:
SHANNON
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, MSA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KAUFFMAN
Provider Other First Name:
SHANNON
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT, MSA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598084667
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 N COLDWATER RD
Provider Second Line Business Mailing Address:
STE D
Provider Business Mailing Address City Name:
WEIDMAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48893-8845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-546-7490
Provider Business Mailing Address Fax Number:
989-563-5953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 N COLDWATER RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
WEIDMAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48893-8845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-546-7490
Provider Business Practice Location Address Fax Number:
989-546-7298
Provider Enumeration Date:
05/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501014675 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5501014675 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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