Provider Demographics
NPI:1366438228
Name:ROSENBERG, PETER MARC (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:MARC
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 212TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2526
Mailing Address - Country:US
Mailing Address - Phone:718-224-2022
Mailing Address - Fax:718-631-7082
Practice Address - Street 1:2619 212TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2526
Practice Address - Country:US
Practice Address - Phone:718-224-2022
Practice Address - Fax:718-631-7082
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127592174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
98953Medicare ID - Type Unspecified
B88887Medicare UPIN