Healthcare Provider Details

I. General information

NPI: 1265422505
Provider Name (Legal Business Name): SEYMOUR J ROSENBLOOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 CHURCH STREET NW
MARIETTA GA
30060-1155
US

IV. Provider business mailing address

625 CHURCH STREET NW
MARIETTA GA
30060-1155
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-2004
  • Fax: 770-422-8465
Mailing address:
  • Phone: 770-422-2004
  • Fax: 770-422-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number015849
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: