Provider Demographics
NPI:1639599293
Name:ROSENTHAL, ELYSE SARAH (DO)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:SARAH
Last Name:ROSENTHAL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1991 SPROUL RD STE 625
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3524
Practice Address - Country:US
Practice Address - Phone:610-325-0309
Practice Address - Fax:610-325-0459
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
PAOS018627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program