Provider Demographics
NPI:1588656896
Name:ROSENBAUM, RICHARD BARRY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BARRY
Last Name:ROSENBAUM
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 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1600 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1426
Practice Address - Country:US
Practice Address - Phone:503-963-3100
Practice Address - Fax:503-459-5398
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD106792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1051580Medicaid
OR235770Medicaid
WA1051580Medicaid
OR013WDBBFBMedicare ID - Type Unspecified
OR143474Medicare PIN