Provider Demographics
NPI:1609861509
Name:ROSENBLUM, JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:ROSENBLUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-706-8526
Mailing Address - Fax:219-531-0859
Practice Address - Street 1:824 LINCOLNWAY
Practice Address - Street 2:LOFT #2
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3411
Practice Address - Country:US
Practice Address - Phone:219-380-5724
Practice Address - Fax:219-575-7345
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001043A207RC0000X, 207R00000X, 207RI0011X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID100356180AMedicaid
IN100356180Medicaid
IN000000540070OtherANTHEM, BCBS
IN000000792854OtherANTHEM
ININ1132001Medicare PIN
IN151020MMMMedicare PIN
IN100356180Medicaid