Provider Demographics
NPI:1053351395
Name:ROSEN, LISA S (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:ROSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 KING OF PRUSSIA RD
Mailing Address - Street 2:
Mailing Address - City:RADNOR
Mailing Address - State:PA
Mailing Address - Zip Code:19087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 KING OF PRUSSIA RD
Practice Address - Street 2:
Practice Address - City:RADNOR
Practice Address - State:PA
Practice Address - Zip Code:19087
Practice Address - Country:US
Practice Address - Phone:610-902-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035433E207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011354810001Medicaid
C33547Medicare UPIN
PA0011354810001Medicaid