Healthcare Provider Details

I. General information

NPI: 1508857129
Provider Name (Legal Business Name): RANDY ALLEN ROSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 03/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 HARRODSBURG RD C-335
LEXINGTON KY
40504
US

IV. Provider business mailing address

1401 HARRODSBURG RD C-335
LEXINGTON KY
40504
US

V. Phone/Fax

Practice location:
  • Phone: 859-276-5355
  • Fax: 859-275-1630
Mailing address:
  • Phone: 859-276-5355
  • Fax: 859-275-1630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD035327E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number42958
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: