Basic Information
| Provider Information | |||||||||
| NPI: | 1356379564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSENBERG | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JACOB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 COX RD | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230609263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049685700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 E PARHAM RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232283118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042647808 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101047611 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080125856V | 01 | VA | RAILROAD MEDICARE | OTHER | 5526500 | 01 | VA | AETNA LIFE | OTHER | 254731 | 01 | VA | MAMSI | OTHER | 79136 | 01 | VA | SOUTHERN HEALTH SERVICES | OTHER | C05698 | 01 | VA | GROUP PTAN | OTHER | 005811708 | 05 | VA | MEDICAID | 204503 | 01 | VA | ANTHEM BCBS OF VA | OTHER | 45891 | 01 | VA | SENTARA | OTHER | 5526500 | 01 | VA | AETNA HMO | OTHER | 1440250 | 01 | VA | CIGNA | OTHER |