Basic Information
| Provider Information | |||||||||
| NPI: | 1801935325 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROSENGARD CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 61137 | ||||||||
| Address2: | |||||||||
| City: | LONGMEADOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011166137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132147435 | ||||||||
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| Practice Location | |||||||||
| Address1: | 380 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021272215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172681500 | ||||||||
| FaxNumber: | 6172698558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROSENGARD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6172681500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20854 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9740325 | 05 | MA | MEDICAID |