Provider Demographics
NPI:1457342602
Name:ROSENBERG, BETH MAXINE (PAC)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:MAXINE
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13640 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4846
Mailing Address - Country:US
Mailing Address - Phone:623-876-3800
Mailing Address - Fax:623-583-5816
Practice Address - Street 1:14416 W MEEKER BLVD
Practice Address - Street 2:BLDG C
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5284
Practice Address - Country:US
Practice Address - Phone:623-583-5100
Practice Address - Fax:623-583-5816
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3002207P00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ878720Medicaid
AZAW1436OtherHEALTHNET GRP
AZ3981220OtherEVERCARE
AZZ103358Medicare PIN
AZ3981220OtherEVERCARE
AZP00239900Medicare PIN
AZS59466Medicare UPIN
AZZ114620Medicare PIN