Healthcare Provider Details

I. General information

NPI: 1639419971
Provider Name (Legal Business Name): MICHAEL ROSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2013
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 E MAUMEE ST STE 204
ANGOLA IN
46703-2038
US

IV. Provider business mailing address

5050 N CLINTON ST
FORT WAYNE IN
46825-5822
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-4007
  • Fax: 260-266-7355
Mailing address:
  • Phone: 260-484-8551
  • Fax: 260-482-5060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS15287
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02005783A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number34.017638
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: