Provider Demographics
NPI:1891812087
Name:JERRY H ROSENBERG MD
Entity Type:Organization
Organization Name:JERRY H ROSENBERG MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONELLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:5504-887-5555
Mailing Address - Street 1:4224 HOUMA BLVD
Mailing Address - Street 2:260
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2933
Mailing Address - Country:US
Mailing Address - Phone:504-887-5555
Mailing Address - Fax:504-888-5031
Practice Address - Street 1:67250 INDUSTRY LN
Practice Address - Street 2:SUITE B
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8716
Practice Address - Country:US
Practice Address - Phone:985-892-3456
Practice Address - Fax:985-892-3499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010614261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1365939Medicaid
LA1365939Medicaid
LAB62153Medicare UPIN