Healthcare Provider Details

I. General information

NPI: 1194923417
Provider Name (Legal Business Name): MARTIN ANDERS ROSENGREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2007
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

153 MASON WAY
MADISON MS
39110
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-4001
  • Fax:
Mailing address:
  • Phone: 601-605-4516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA111925
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number695-L
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: