Basic Information
| Provider Information | |||||||||
| NPI: | 1508857129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 HARRODSBURG RD | ||||||||
| Address2: | C-335 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592765355 | ||||||||
| FaxNumber: | 8592751630 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 HARRODSBURG RD | ||||||||
| Address2: | C-335 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592765355 | ||||||||
| FaxNumber: | 8592751630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 03/22/2010 | ||||||||
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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 | 207RN0300X | MD035327E | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 42958 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1048161 | 05 | PA | MEDICAID | 110029895 | 01 | RR MEDICARE | OTHER | 1912005117 | 05 | KY | MEDICAID |