Provider Demographics
NPI:1285316976
Name:ROSENBERGER, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ROSENBERGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:MN
Mailing Address - Zip Code:56307-9328
Mailing Address - Country:US
Mailing Address - Phone:320-339-0474
Mailing Address - Fax:
Practice Address - Street 1:820 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:MN
Practice Address - Zip Code:56307-9328
Practice Address - Country:US
Practice Address - Phone:320-339-0474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNZ996251476524172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN384666OtherSTS