Provider Demographics
NPI:1710151444
Name:INSTITUTE FOR HEALTHY AGING INC
Entity Type:Organization
Organization Name:INSTITUTE FOR HEALTHY AGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-272-1956
Mailing Address - Street 1:PO BOX 1759
Mailing Address - Street 2:DEPT. 952
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77251-1759
Mailing Address - Country:US
Mailing Address - Phone:713-554-5304
Mailing Address - Fax:713-554-5320
Practice Address - Street 1:2512 N FEDERAL HWY
Practice Address - Street 2:SUITE 105
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483-6147
Practice Address - Country:US
Practice Address - Phone:561-272-1956
Practice Address - Fax:561-272-1992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070312207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5738Medicare PIN