Basic Information
| Provider Information | |||||||||
| NPI: | 1801881677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROETHEL | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HEALTHY WAY | ||||||||
| Address2: | ATTN: PHYSICIAN BILLING DEPT | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115721551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162551600 | ||||||||
| FaxNumber: | 5162554672 | ||||||||
| Practice Location | |||||||||
| Address1: | 196 MERRICK RD | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115721420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162551616 | ||||||||
| FaxNumber: | 5162554672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 184344 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01425149 | 05 | NY | MEDICAID | 184344 | 01 | NY | HIP | OTHER | GP160 | 01 | NY | OXFORD | OTHER | 000000071571 | 01 | NY | GHI HMO | OTHER | 5903664 | 01 | NY | GHI PPO | OTHER | 0D4451 | 01 | NY | BCBS | OTHER | 5022479 | 01 | NY | AETNA PPO | OTHER | 5782299 | 01 | NY | CIGNA | OTHER | AA71640 | 01 | NY | MDNY | OTHER | 1000021935 | 01 | NY | AFFINITY | OTHER | 2C9292 | 01 | NY | HEALTHNET | OTHER | 519648 | 01 | NY | AETNA HMO | OTHER |