Provider Demographics
NPI:1508946021
Name:ROOSENBERG, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ROOSENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:551 LINN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1595
Mailing Address - Country:US
Mailing Address - Phone:269-673-2158
Mailing Address - Fax:269-686-2087
Practice Address - Street 1:551 LINN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1595
Practice Address - Country:US
Practice Address - Phone:269-673-2158
Practice Address - Fax:269-686-2087
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301039017207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0030774OtherBCBS
MI2091069Medicaid
MIB44534Medicare UPIN
MI0030774OtherBCBS