Provider Demographics
NPI:1962584292
Name:ROSENBERG, MIRIAM R (MD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:R
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 GLEZEN LANE
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778
Mailing Address - Country:US
Mailing Address - Phone:508-358-7512
Mailing Address - Fax:
Practice Address - Street 1:206 GLEZEN LANE
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778
Practice Address - Country:US
Practice Address - Phone:508-358-7512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA367432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
B49029Medicare UPIN