Provider Demographics
NPI:1063692556
Name:MATT T ROSENBERG PC
Entity type:Organization
Organization Name:MATT T ROSENBERG PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-784-9189
Mailing Address - Street 1:214 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1903
Mailing Address - Country:US
Mailing Address - Phone:517-784-9189
Mailing Address - Fax:517-784-9657
Practice Address - Street 1:214 N WEST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1903
Practice Address - Country:US
Practice Address - Phone:517-784-9189
Practice Address - Fax:517-784-9657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3388780Medicaid
MI0N94000Medicare PIN
MI3388780Medicaid