Provider Demographics
NPI:1255324596
Name:ROSENBAUM, ROBERT ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
Last Name:ROSENBAUM
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 1:975 SE SANDY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1308
Mailing Address - Country:US
Mailing Address - Phone:503-963-2846
Mailing Address - Fax:503-963-9505
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 315
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-963-3100
Practice Address - Fax:503-215-2375
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD083622084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR236448Medicaid
WA1302231Medicaid
ORC91163Medicare UPIN
OR013WDBBFCMedicare ID - Type Unspecified
OR236448Medicaid