Provider Demographics
NPI:1285983197
Name:INGRID ROSEBOROUGH, MD, PC
Entity type:Organization
Organization Name:INGRID ROSEBOROUGH, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-452-4900
Mailing Address - Street 1:3300 WEBSTER ST STE 509
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3149
Mailing Address - Country:US
Mailing Address - Phone:510-452-4900
Mailing Address - Fax:510-452-2152
Practice Address - Street 1:3300 WEBSTER ST STE 509
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3149
Practice Address - Country:US
Practice Address - Phone:510-452-4900
Practice Address - Fax:510-452-2152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92548207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGW698AMedicare PIN
CAGX926XMedicare PIN