Basic Information
Provider Information | |||||||||
NPI: | 1144273905 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSENBERG | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1820 SIDEWINDER DR | ||||||||
Address2: |   | ||||||||
City: | PARK CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 840607492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356556600 | ||||||||
FaxNumber: | 4356552388 | ||||||||
Practice Location | |||||||||
Address1: | 1820 SIDEWINDER DR | ||||||||
Address2: |   | ||||||||
City: | PARK CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 840607492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356556600 | ||||||||
FaxNumber: | 4356552388 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 10/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 157189-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 35743 | 01 | UT | DESERET MUTUAL INS ASSOC | OTHER | 841433992R02 | 01 | UT | EDUCATORS MUTUAL | OTHER | 0990205 | 01 | UT | UNITED HEALTH CARE | OTHER | QM0000040458 | 01 | UT | ALTIUS HEALTH PLANS | OTHER | 60843 | 01 | UT | PUBLIC EMPLOYEES HEALTH P | OTHER | TPRA09041 | 01 | UT | MOLINA | OTHER | 107005202101 | 01 | UT | SELECT HEALTH PLANS | OTHER |