Provider Demographics
NPI:1801935325
Name:ROSENGARD CLINIC
Entity type:Organization
Organization Name:ROSENGARD CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROSENGARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-268-1500
Mailing Address - Street 1:PO BOX 61137
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01116-6137
Mailing Address - Country:US
Mailing Address - Phone:413-214-7435
Mailing Address - Fax:
Practice Address - Street 1:380 W BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2215
Practice Address - Country:US
Practice Address - Phone:617-268-1500
Practice Address - Fax:617-269-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9740325Medicaid
MAM10214Medicare ID - Type Unspecified