Healthcare Provider Details

I. General information

NPI: 1609861509
Provider Name (Legal Business Name): JOSEPH ROSENBLUM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 LINCOLNWAY LOFT #2
LA PORTE IN
46350-3411
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 219-380-5724
  • Fax: 219-575-7345
Mailing address:
  • Phone: 208-706-8526
  • Fax: 219-531-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number02001043A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02001043A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number02001043A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number02001043A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number02001043A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: