Basic Information
| Provider Information | |||||||||
| NPI: | 1588101091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14680 BORGMAN ST | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482371156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489902409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1964 W 11 MILE RD | ||||||||
| Address2: | |||||||||
| City: | BERKLEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480723046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485449300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2017 | ||||||||
| LastUpdateDate: | 01/22/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5601008082 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.