Provider Demographics
NPI:1639187719
Name:ROSEN, ROBERT STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:STANLEY
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 1:3201 OLD GLENVIEW RD STE 130
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2964
Mailing Address - Country:US
Mailing Address - Phone:847-674-4344
Mailing Address - Fax:847-674-4377
Practice Address - Street 1:3201 OLD GLENVIEW RD STE 130
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2964
Practice Address - Country:US
Practice Address - Phone:847-674-4344
Practice Address - Fax:847-674-4377
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068569208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068569Medicaid
ILC44004Medicare UPIN
IL603050001Medicare PIN
IL036068569Medicaid