Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 246743 | NY |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 255329 | MA |
NPI | 1932370178 |
---|---|
Provider Name | Robert J Roose |
First Address | Holyoke, MA 01040-5381 |
Second Address | Holyoke, MA 01040-5381 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/03/2008 |
Last Update Date | 11/02/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00245643 | (05) | NY |