Healthcare Provider Details

I. General information

NPI: 1366652547
Provider Name (Legal Business Name): THOMAS M ROSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9650 GROSS POINT RD STE 29
SKOKIE IL
60076-5080
US

IV. Provider business mailing address

9650 GROSS POINT RD STE 2900
SKOKIE IL
60076-5006
US

V. Phone/Fax

Practice location:
  • Phone: 847-866-7846
  • Fax: 224-251-5074
Mailing address:
  • Phone: 478-667-8468
  • Fax: 224-251-5074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085-002318
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: