Basic Information
| Provider Information | |||||||||
| NPI: | 1669472932 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSENSTEIN | ||||||||
| FirstName: | JEROME | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120781203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187754205 | ||||||||
| FaxNumber: | 5187754225 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HARRISON STREET | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638205 | ||||||||
| FaxNumber: | 6077638208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 10/12/2017 | ||||||||
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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 | 207V00000X | 224098 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 02229110 | 05 | NY | MEDICAID |