1609861509 NPI number — JOSEPH ROSENBLUM DO

Table of content: JOSEPH ROSENBLUM DO (NPI 1609861509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609861509 NPI number — JOSEPH ROSENBLUM DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSENBLUM
Provider First Name:
JOSEPH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1609861509
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 E BANNOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83712-6241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-706-8526
Provider Business Mailing Address Fax Number:
219-531-0859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
824 LINCOLNWAY
Provider Second Line Business Practice Location Address:
LOFT #2
Provider Business Practice Location Address City Name:
LA PORTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46350-3411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-380-5724
Provider Business Practice Location Address Fax Number:
219-575-7345
Provider Enumeration Date:
09/16/2005

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: 207RC0000X , with the licence number:  02001043A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 02001043A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: 02001043A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: 02001043A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X , with the licence number: 02001043A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100356180A , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100356180 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000540070 . This is a "ANTHEM, BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000792854 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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