Provider Demographics
NPI:1629582739
Name:ROSENBERGER, ADDIE C (PA-C)
Entity Type:Individual
Prefix:
First Name:ADDIE
Middle Name:C
Last Name:ROSENBERGER
Suffix:
Gender:F
Credentials:PA-C
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:200 E CHESTNUT ST BLDG STE 303
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1831
Practice Address - Country:US
Practice Address - Phone:502-629-5552
Practice Address - Fax:502-629-3132
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
KYPA2487363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300026056Medicaid
KYK303770OtherMEDICARE
KY7100593600Medicaid