Provider Demographics
NPI:1730490509
Name:ROSENBERG, SAMUEL JAY (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JAY
Last Name:ROSENBERG
Suffix:
Gender:M
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:PO BOX 751
Mailing Address - Street 2:
Mailing Address - City:TALLMAN
Mailing Address - State:NY
Mailing Address - Zip Code:10982-0751
Mailing Address - Country:US
Mailing Address - Phone:212-305-3535
Mailing Address - Fax:212-342-1470
Practice Address - Street 1:26 FIREMENS MEMORIAL DR STE 120
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3576
Practice Address - Country:US
Practice Address - Phone:845-709-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-27
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY265958208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWXVTR1Medicare PIN