Provider Demographics
NPI:1427137355
Name:ROSENBAUM, JEFFREY DALE (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DALE
Last Name:ROSENBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:18618 MIDDLEBELT RD
Mailing Address - Street 2:SUITE #102
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3585
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18618 MIDDLEBELT RD
Practice Address - Street 2:SUITE #102
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3586
Practice Address - Country:US
Practice Address - Phone:248-476-1010
Practice Address - Fax:248-476-9239
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101008667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI58221276011Medicare ID - Type Unspecified
MIB45574Medicare UPIN