Provider Demographics
NPI:1356379564
Name:ROSENBERG, MARK JACOB (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JACOB
Last Name:ROSENBERG
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:2300 E PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-3118
Practice Address - Country:US
Practice Address - Phone:804-264-7808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080125856VOtherRAILROAD MEDICARE
VA5526500OtherAETNA LIFE
VA254731OtherMAMSI
VA79136OtherSOUTHERN HEALTH SERVICES
VAC05698OtherGROUP PTAN
VA005811708Medicaid
VA204503OtherANTHEM BCBS OF VA
VA45891OtherSENTARA
VA5526500OtherAETNA HMO
VA1440250OtherCIGNA
C96521Medicare UPIN
VA080006567Medicare ID - Type Unspecified