Provider Demographics
NPI:1679591168
Name:ROSENBERG, BRADLEY L (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:L
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 1:333 KENNEDY DR
Mailing Address - Street 2:SUITE L-104
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-3060
Mailing Address - Country:US
Mailing Address - Phone:860-496-4043
Mailing Address - Fax:860-496-4046
Practice Address - Street 1:333 KENNEDY DR
Practice Address - Street 2:SUITE L-104
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3060
Practice Address - Country:US
Practice Address - Phone:860-496-4043
Practice Address - Fax:860-496-4046
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010033543CT01OtherBLUE CROSS
CT1335430Medicaid
CT2V0428OtherHEALTH NET OF CT
CT335430OtherCONNECTICARE
CT2639112OtherAETNA
CT080001509Medicare ID - Type Unspecified
E70975Medicare UPIN