Provider Demographics
NPI:1255301297
Name:ROSENBAUM, EDWARD (PHD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:ROSENBAUM
Suffix:
Gender:M
Credentials:PHD
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 3188
Mailing Address - Street 2:
Mailing Address - City:MAPLE GLEN
Mailing Address - State:PA
Mailing Address - Zip Code:19002-8188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8302 YORK RD
Practice Address - Street 2:STE 2
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027
Practice Address - Country:US
Practice Address - Phone:215-572-6292
Practice Address - Fax:215-572-6292
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS001409L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1400141Medicaid
PAJ29666OtherINTERCOUNTY
PA0049190000OtherBLUESHIELD PERSONACHOICE
PA0140014101OtherAMERICHOICE
PAJ29666OtherINTERCOUNTY
PA029666Medicare ID - Type Unspecified