Healthcare Provider Details

I. General information

NPI: 1114595105
Provider Name (Legal Business Name): LILY M ROSENBERG MS-PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NORTHERN BLVD
ALBANY NY
12204-1083
US

IV. Provider business mailing address

6 HIDLEY AVE
WYNANTSKILL NY
12198-7920
US

V. Phone/Fax

Practice location:
  • Phone: 518-471-3221
  • Fax:
Mailing address:
  • Phone: 518-496-2278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number027040
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: