Healthcare Provider Details

I. General information

NPI: 1700907896
Provider Name (Legal Business Name): JERRY M ROSENBAUM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 BAY COURT
SAN RAFAEL CA
94901
US

IV. Provider business mailing address

6 BAY COURT
SAN RAFAEL CA
94901
US

V. Phone/Fax

Practice location:
  • Phone: 305-505-7180
  • Fax: 415-785-4176
Mailing address:
  • Phone: 305-505-7180
  • Fax: 415-785-4176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberME33938
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberME33938
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: