Basic Information
| Provider Information | |||||||||
| NPI: | 1700963568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | RAYMOND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 GEORGE ST | ||||||||
| Address2: | UNIVERSITY MEDICAL GROUP 3RD FLOOR | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089012008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322358282 | ||||||||
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| Practice Location | |||||||||
| Address1: | 125 PATERSON ST | ||||||||
| Address2: | CLINICAL ACADEMIC BUILDING - SUITE 2200 | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322357647 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 103T00000X | NJ | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0830909 | 05 | NJ | MEDICAID |