Provider Demographics
NPI:1801934245
Name:ROSENBAUM, MARJORIE MINTZ (MD)
Entity type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:MINTZ
Last Name:ROSENBAUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST
Mailing Address - Street 2:SUITE 1725
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-664-8533
Mailing Address - Fax:312-664-8860
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 1725
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-664-8533
Practice Address - Fax:312-664-8860
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-065456207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15444Medicare UPIN
204237Medicare ID - Type UnspecifiedMEDICARE PROVIDER #