Basic Information
| Provider Information | |||||||||
| NPI: | 1033459292 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEROME H ROSENSTEIN MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 HARRISON ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638205 | ||||||||
| FaxNumber: | 6077638208 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HARRISON ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638205 | ||||||||
| FaxNumber: | 6077638208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2013 | ||||||||
| LastUpdateDate: | 02/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | ROSENSTEIN | ||||||||
| AuthorizedOfficialFirstName: | JEROME | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6077638205 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2240981 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 02229110 | 05 | NY | MEDICAID |