Basic Information
| Provider Information | |||||||||
| NPI: | 1811944549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | LUBA | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 PINE GROVE ST | ||||||||
| Address2: | |||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024941766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177346135 | ||||||||
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| Practice Location | |||||||||
| Address1: | 637 WASHINGTON ST | ||||||||
| Address2: | #102 | ||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024464500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177346135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 12/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 151234 | MA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 3181146 | 05 | MA | MEDICAID |