Healthcare Provider Details

I. General information

NPI: 1730172040
Provider Name (Legal Business Name): PAUL ANDREW ROZEBOOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JACK FOSTER DR
SHENANDOAH IA
51601-4586
US

IV. Provider business mailing address

300 PERSHING AVE
SHENANDOAH IA
51601-2355
US

V. Phone/Fax

Practice location:
  • Phone: 712-246-7400
  • Fax: 712-246-7334
Mailing address:
  • Phone: 712-246-1230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number32107
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: