Basic Information
| Provider Information | |||||||||
| NPI: | 1407969777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSENBERG | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100523 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295010523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Practice Location | |||||||||
| Address1: | 4731 HWY 17 BYPASS SOUTH | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295762673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438397246 | ||||||||
| FaxNumber: | 8438397323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | 24751 | SC | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 202435512 | 01 | SC | STANDARD TAX ID | OTHER | 247512 | 05 | SC | MEDICAID |