Provider Demographics
NPI:1023080702
Name:ROSENOW, MARY K (MD, PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:ROSENOW
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 POSSUM RD
Mailing Address - Street 2:
Mailing Address - City:TUNNEL HILL
Mailing Address - State:IL
Mailing Address - Zip Code:62972-3138
Mailing Address - Country:US
Mailing Address - Phone:270-994-6969
Mailing Address - Fax:
Practice Address - Street 1:1135 POSSUM RD
Practice Address - Street 2:
Practice Address - City:TUNNEL HILL
Practice Address - State:IL
Practice Address - Zip Code:62972-3138
Practice Address - Country:US
Practice Address - Phone:270-994-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL036060221208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060221Medicaid
C45787Medicare UPIN
203315Medicare ID - Type Unspecified