Provider Demographics
NPI:1841248192
Name:ROSEN, MARK J (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:ROSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12000 BUSTLETON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-2151
Mailing Address - Country:US
Mailing Address - Phone:215-677-8870
Mailing Address - Fax:
Practice Address - Street 1:12000 BUSTLETON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-2151
Practice Address - Country:US
Practice Address - Phone:215-677-8870
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT002807L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA110211OtherBLUE SHIELD
PA110211UAAMedicare ID - Type Unspecified