Basic Information
| Provider Information | |||||||||
| NPI: | 1447215546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSKOS | ||||||||
| FirstName: | RUDOLPH | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1608 SE 3RD AVE | ||||||||
| Address2: | THIRD FLOOR CBO-PBS | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548474273 | ||||||||
| FaxNumber: | 9548474176 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S ANDREWS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543554527 | ||||||||
| FaxNumber: | 9544685251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 08/27/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME71189 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0207X | ME71189 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 250418900 | 05 | FL | MEDICAID |