Provider Demographics
NPI:1407827827
Name:ROSENWASSER, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ROSENWASSER
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 1:47601 GRAND RIVER AVE
Mailing Address - Street 2:B223
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1233
Mailing Address - Country:US
Mailing Address - Phone:248-465-4800
Mailing Address - Fax:248-465-4872
Practice Address - Street 1:47601 GRAND RIVER AVE
Practice Address - Street 2:B223
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1233
Practice Address - Country:US
Practice Address - Phone:248-465-4800
Practice Address - Fax:248-465-4872
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043868207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301043868OtherCONTROLLED SUBSTANCE
AR1298644OtherDEA
MI4301043868OtherCONTROLLED SUBSTANCE