Basic Information
| Provider Information | |||||||||
| NPI: | 1255513842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROZENBERG | ||||||||
| FirstName: | SVETLANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROZENBERG | ||||||||
| OtherFirstName: | SVETLANA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 375 MCCARTER HWY | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071142562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736438601 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 375 MCCARTER HWY | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071142562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736434969 | ||||||||
| FaxNumber: | 9736433657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2007 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 25MP00096300 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.