Provider Demographics
NPI:1053412767
Name:ROSENBERG, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:725 RESERVOIR AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4448
Mailing Address - Country:US
Mailing Address - Phone:401-943-6910
Mailing Address - Fax:401-946-5130
Practice Address - Street 1:725 RESERVOIR AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4448
Practice Address - Country:US
Practice Address - Phone:401-943-6910
Practice Address - Fax:401-946-5130
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2016-04-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
RIMD09624207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H34714Medicare UPIN
RI089024193Medicare PIN