Healthcare Provider Details

I. General information

NPI: 1528320397
Provider Name (Legal Business Name): JILLIAN ROSENGARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST DEPT OF
BRONX NY
10467-2401
US

IV. Provider business mailing address

111 EAST 210TH STREET DEPT OF NEUROLOGY, NW1 ROOM 002
BRONX NY
10467
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4898
  • Fax: 718-515-0697
Mailing address:
  • Phone: 718-920-4898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number273318
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: