Provider Demographics
NPI:1811996259
Name:ROSENBAUM, MARK ALLAN (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLAN
Last Name:ROSENBAUM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-5866
Mailing Address - Country:US
Mailing Address - Phone:269-375-6565
Mailing Address - Fax:269-375-7168
Practice Address - Street 1:4403 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5866
Practice Address - Country:US
Practice Address - Phone:269-375-6565
Practice Address - Fax:269-375-7168
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004304111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950C950380OtherBCN
MI950C950380OtherBCBS
MI950C950380OtherBCBS