Provider Demographics
NPI:1124059951
Name:LEONARD J. ROSEN, M.D. PC
Entity type:Organization
Organization Name:LEONARD J. ROSEN, M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-246-7477
Mailing Address - Street 1:30538 FOX CLUB DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1988
Mailing Address - Country:US
Mailing Address - Phone:734-246-7447
Mailing Address - Fax:
Practice Address - Street 1:30538 FOX CLUB DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-1988
Practice Address - Country:US
Practice Address - Phone:734-246-7447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033083261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MILR033083OtherLIC #
MI1089146Medicaid
MI2608282111OtherBCBS #
MI0508211Medicare PIN
MI1089146Medicaid