Provider Demographics
NPI:1609879196
Name:ROSEBERRY, ELIZABETH ANN (MD)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:ROSEBERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 EAGLE PASS DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-8138
Mailing Address - Country:US
Mailing Address - Phone:740-382-3511
Mailing Address - Fax:740-382-0682
Practice Address - Street 1:1446 EAGLE PASS DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-8138
Practice Address - Country:US
Practice Address - Phone:740-382-3511
Practice Address - Fax:740-382-0682
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2009-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH07742080N0001X
VA01010450482080N0001X
WV171202080N0001X
OH350798752080N0001X
IDM91822080N0001X
CO435792080N0001X
ND107022080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV17120OtherMEDICAL LICENSE
ND10702OtherSTATE LICENSE
TXH0774OtherMEDICAL LICENSE
VA0101045048OtherMEDICAL LICENSE
OH35079875OtherMEDICAL LICENSE
CO43579OtherMEDICAL LICENSE
IDM9182OtherMEDICAL LICENSE
E36571Medicare UPIN