Provider Demographics
NPI:1356346399
Name:ROSENTHAL, ELI A (MD)
Entity type:Individual
Prefix:DR
First Name:ELI
Middle Name:A
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:MD
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 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:1040 NW 22ND AVE, SUITE 660
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-413-7162
Practice Address - Fax:503-413-7148
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17870174400000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR046024Medicaid
OR804330005OtherBLUE CROSS BLUE SHIELD
OR804330005OtherBLUE CROSS BLUE SHIELD
ORF37781Medicare UPIN
OR111263Medicare ID - Type Unspecified