Healthcare Provider Details

I. General information

NPI: 1437595642
Provider Name (Legal Business Name): PHILIP ROSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 N CAMPBELL AVE
TUCSON AZ
85724-2012
US

IV. Provider business mailing address

450 CLARKSON AVE # 1262 DEPARTMENT OF SURGERY, SUNY DOWNSTATE MEDICAL CENTER
BROOKLYN NY
11203-2012
US

V. Phone/Fax

Practice location:
  • Phone: 111-111-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number1437595642
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: