Healthcare Provider Details

I. General information

NPI: 1972131845
Provider Name (Legal Business Name): LOGAN KYLE ROSENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 LEWIS AVE STE 206
MERIDEN CT
06451-2121
US

IV. Provider business mailing address

1290 SILAS DEANE HWY
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 203-238-9446
  • Fax:
Mailing address:
  • Phone: 860-972-9093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number85844
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number85844
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: