Basic Information
| Provider Information | |||||||||
| NPI: | 1336179340 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSENBERG | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 E NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532123515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142676502 | ||||||||
| FaxNumber: | 4142673892 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 N LAKE DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142987100 | ||||||||
| FaxNumber: | 4142987101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44786 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207N00000X | 44786 | WI | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 1336179340 | 05 | WI | MEDICAID |