Provider Demographics
NPI:1043278138
Name:ROSEN, SY H (CO)
Entity Type:Individual
Prefix:
First Name:SY
Middle Name:H
Last Name:ROSEN
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3549 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60203-1819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9933 LAWLER AVE
Practice Address - Street 2:#409
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-3703
Practice Address - Country:US
Practice Address - Phone:847-410-2751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213000062222Z00000X
224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL99322112OtherBLUE CROSS
IL99322112OtherBLUE CROSS