Provider Demographics
NPI:1184601510
Name:ROSENBERG, MARK STEPHEN (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEPHEN
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 1:2405 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5961
Mailing Address - Country:US
Mailing Address - Phone:586-264-1800
Mailing Address - Fax:586-264-1155
Practice Address - Street 1:2405 E FOURTEEN MILE RD
Practice Address - Street 2:MACOMB MEDICAL CLINIC PC
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310
Practice Address - Country:US
Practice Address - Phone:586-264-1800
Practice Address - Fax:586-264-1155
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2594353Medicaid
MI2594353Medicaid
MIM32970009Medicare PIN
MIM32970009Medicare PIN