Provider Demographics
NPI:1588710248
Name:ROSENBERG A REYES M D PSC
Entity type:Organization
Organization Name:ROSENBERG A REYES M D PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSENBERG
Authorized Official - Middle Name:A
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-368-2563
Mailing Address - Street 1:4314 SEAGRAPE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-4086
Mailing Address - Country:US
Mailing Address - Phone:502-297-9959
Mailing Address - Fax:
Practice Address - Street 1:320 W WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-1924
Practice Address - Country:US
Practice Address - Phone:502-368-2563
Practice Address - Fax:502-368-2427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64004104Medicaid
KYG97206Medicare UPIN
KY64004104Medicaid