Provider Demographics
NPI:1346559192
Name:GARY S ROSENBAUM MD PC
Entity Type:Organization
Organization Name:GARY S ROSENBAUM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-727-6122
Mailing Address - Street 1:887 OLD COUNTRY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2115
Mailing Address - Country:US
Mailing Address - Phone:631-727-6122
Mailing Address - Fax:631-727-2672
Practice Address - Street 1:887 OLD COUNTRY RD
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2115
Practice Address - Country:US
Practice Address - Phone:631-727-6122
Practice Address - Fax:631-727-2672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1735421207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011924229Medicaid
NY041F522Medicare PIN