Provider Demographics
NPI:1629064118
Name:ROSEN, LAWRENCE S (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:S
Last Name:ROSEN
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 339
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265
Mailing Address - Country:US
Mailing Address - Phone:256-435-1871
Mailing Address - Fax:256-435-5703
Practice Address - Street 1:201 HENRY RD SW
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265-3324
Practice Address - Country:US
Practice Address - Phone:256-435-1871
Practice Address - Fax:256-435-5703
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000014553Medicaid
AL000014553Medicare ID - Type Unspecified
AL000014553Medicaid