1114900925 NPI number — DR. BONNIE SUE ROSEN MD

Table of content: DR. BONNIE SUE ROSEN MD (NPI 1114900925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114900925 NPI number — DR. BONNIE SUE ROSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSEN
Provider First Name:
BONNIE
Provider Middle Name:
SUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1114900925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 SCENIC VIEW CT EAST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIX HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-901-9993
Provider Business Mailing Address Fax Number:
612-294-4903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 MEDFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PATCHOGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11772-1281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-595-1100
Provider Business Practice Location Address Fax Number:
612-294-4903
Provider Enumeration Date:
11/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  184808-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 184808 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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