Ty Martin Roseberry, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

19182 Issued in CA

Practice address

1801 N Senate Blvd
#200
Indianapolis, IN 46202-1228

Phone

(317) 802-2000

Fax

(317) 924-0115

NPI assigned

May 12, 2006

Last updated

Nov 29, 2021By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2003

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Southern California Permanente Medical GroupGroup PAC ID 6002729175, 11,250 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Riverside, CA
  • NPI 1316979834
  Medicare reassignment Care Compare group
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Fontana, CA
  • NPI 1689606196
  NPD
• Orthopaedics-Indianapolis, Inc

  dba Orthoindy-Northwest

  • Orthopaedic Surgery Physician
  • Indianapolis, IN
  • NPI 1073622015
  NPD (past)
• Emergency Medicine Physician Partners of San Bernardino County, Inc

  • Emergency Medicine Physician
  • San Bernardino, CA
  • NPI 1225339294
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147392000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1638144000000",
    "number": "1487604948",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "14380 MAIN ST",
            "address_2": "SUITE 120, PMB 160",
            "city": "HESPERIA",
            "state": "CA",
            "postal_code": "923454613",
            "telephone_number": "760-947-3220"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1801 N SENATE BLVD",
            "address_2": "#200",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462021228",
            "telephone_number": "317-802-2000",
            "fax_number": "317-924-0115"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROSEBERRY",
        "first_name": "TY",
        "middle_name": "MARTIN",
        "name_prefix": "Mr.",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-12",
        "last_updated": "2021-11-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "IN",
            "license": "10000768A",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "19182",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Southern California Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "10800 Magnolia Ave",
            "city": "Riverside",
            "state": "CA",
            "country_code": "US",
            "postal_code": "925053043",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Susan P Rose, MD
• Talisha Marie Rose
• Tracy Sue Rose, AGACNP-BC
• Rose's Comfort LLC
• Kyle David Roseberry
• Evann Rae Rosebrough, CLC
• Ryan Matthew Rosebrough, MPAS, PA-C
• Rosebud Personal Service Agency (RoseBud PSA)
• Carey J Roselee, NP
• Stephen Antatico Rosell

• Physician Assistant in Indianapolis, IN
• Providers in Indianapolis, IN by specialty
• Physician Assistant in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.