1366625584 NPI number — MICHAEL S ROSEN PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366625584 NPI number — MICHAEL S ROSEN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL S ROSEN PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366625584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2820
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86405-2820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-680-4233
Provider Business Mailing Address Fax Number:
928-680-6522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2082 MESQUITE AVE
Provider Second Line Business Practice Location Address:
SUITE A106
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-6710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-680-4233
Provider Business Practice Location Address Fax Number:
928-680-6522
Provider Enumeration Date:
12/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROSEN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-680-4233

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  30884 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2Z2025 . This is a "HEALTH NET" identifier . This identifiers is of the category "OTHER".
  • Identifier: DD0594 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 744632 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0767860 . This is a "BCBS AZ" identifier . This identifiers is of the category "OTHER".




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