Provider Demographics
NPI:1285679134
Name:ROSENBERG, LORI WOLFE (MD)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:WOLFE
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:MICHELLE
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1401 CENTERVILLE RD
Mailing Address - Street 2:STE 202
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-877-7241
Mailing Address - Fax:850-877-1338
Practice Address - Street 1:1401 CENTERVILLE RD
Practice Address - Street 2:STE 202
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-877-7241
Practice Address - Fax:850-877-1338
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 96354207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276347800Medicaid
FL79749XMedicare PIN
FL276347800Medicaid