Provider Demographics
NPI:1588101091
Name:ROSEN, MARK (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ROSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14680 BORGMAN ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1156
Mailing Address - Country:US
Mailing Address - Phone:248-990-2409
Mailing Address - Fax:
Practice Address - Street 1:1964 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3046
Practice Address - Country:US
Practice Address - Phone:248-544-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-22
Last Update Date:2017-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008082363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical