Provider Demographics
NPI:1639175763
Name:ROSENBERG, JERROLD N (MD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:N
Last Name:ROSENBERG
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 1:827 N MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5751
Mailing Address - Country:US
Mailing Address - Phone:401-453-5030
Mailing Address - Fax:401-453-5033
Practice Address - Street 1:827 N MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5751
Practice Address - Country:US
Practice Address - Phone:401-453-5030
Practice Address - Fax:401-453-5033
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2013-09-19
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
RIMD7222208100000X
RIMD07222208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1134OtherBCBSRI
RI9001134Medicaid
RI200688OtherBLUE CHIP
RI1570/4122OtherNHP
RI200688Medicare UPIN
RI1570/4122OtherNHP
RI007007252Medicare ID - Type Unspecified