Provider Demographics
NPI:1184683765
Name:ROTHENBERG, A JERALD (MD)
Entity Type:Individual
Prefix:
First Name:A
Middle Name:JERALD
Last Name:ROTHENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 ARBELEDA LN
Mailing Address - Street 2:SUITE 408
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-7605
Mailing Address - Country:US
Mailing Address - Phone:847-866-6600
Mailing Address - Fax:847-475-6835
Practice Address - Street 1:2270 ARBELEDA LN
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062
Practice Address - Country:US
Practice Address - Phone:847-254-2453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-039336174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360393361Medicaid
ILL26843Medicare PIN
ILC43297Medicare UPIN