Provider Demographics
NPI:1548398191
Name:ROSENBLUM, MORDECHAY (CO)
Entity Type:Individual
Prefix:
First Name:MORDECHAY
Middle Name:
Last Name:ROSENBLUM
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2689 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3915
Mailing Address - Country:US
Mailing Address - Phone:718-368-1855
Mailing Address - Fax:
Practice Address - Street 1:2689 E 14TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3915
Practice Address - Country:US
Practice Address - Phone:718-368-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCO1917222Z00000X
NJ45PO00005100222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01175933Medicaid
NY0154660001Medicare NSC