Provider Demographics
NPI:1538497300
Name:ROSEBROCK, RICHARD E (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:ROSEBROCK
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:PO BOX 116186
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6186
Mailing Address - Country:US
Mailing Address - Phone:770-834-0751
Mailing Address - Fax:770-834-0753
Practice Address - Street 1:705 DIXIE STREET
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:770-834-0751
Practice Address - Fax:770-834-0753
Is Sole Proprietor?:No
Enumeration Date:2009-12-06
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000454472085R0202X
MN1055252085R0202X
MN545772085R0202X
GA0724462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN300006279Medicare PIN