Provider Demographics
NPI:1649343245
Name:ROSEN, BRUCE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:ROSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2814
Mailing Address - Country:US
Mailing Address - Phone:631-265-6868
Mailing Address - Fax:631-265-6890
Practice Address - Street 1:222 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 210
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2814
Practice Address - Country:US
Practice Address - Phone:631-265-6868
Practice Address - Fax:631-265-6890
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1127152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00204173Medicaid
NY644101Medicare PIN
NY00204173Medicaid