Provider Demographics
NPI:1659345221
Name:ROSENBERG, MICHAEL WARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WARD
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:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7690
Mailing Address - Fax:307-739-7644
Practice Address - Street 1:555 E BROADWAY AVE
Practice Address - Street 2:SUITE #229
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-7690
Practice Address - Fax:307-739-7644
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8000A208600000X
IDM-10577208600000X
NY147502208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00953517Medicaid
WYP01354282OtherPALMETTO GBA MRR
WY127072900Medicaid
WYW26174OtherNORIDIAN MEDICARE SJMC
WY127072900Medicaid
NY00953517Medicaid