Provider Demographics
NPI:1508857129
Name:ROSEN, RANDY ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:ALLEN
Last Name:ROSEN
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 1:1401 HARRODSBURG RD
Mailing Address - Street 2:C-335
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504
Mailing Address - Country:US
Mailing Address - Phone:859-276-5355
Mailing Address - Fax:859-275-1630
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:C-335
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504
Practice Address - Country:US
Practice Address - Phone:859-276-5355
Practice Address - Fax:859-275-1630
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035327E207RN0300X
KY42958207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1048161Medicaid
110029895OtherRR MEDICARE
KY1912005117Medicaid
KY0040913Medicare PIN
KY1912005117Medicaid