Healthcare Provider Details

I. General information

NPI: 1750661104
Provider Name (Legal Business Name): LISA ROSENBERG MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61-34 188TH ST SUITE 214
FRESH MEADOWS NY
11365-2726
US

IV. Provider business mailing address

61-34 188TH ST SUITE 214
FRESH MEADOWS NY
11365-2726
US

V. Phone/Fax

Practice location:
  • Phone: 718-454-3200
  • Fax: 718-454-4191
Mailing address:
  • Phone: 718-454-3200
  • Fax: 718-454-4191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number151716
License Number StateNY

VIII. Authorized Official

Name: LISA ROSENBERG
Title or Position: MD/OWNER
Credential: MD
Phone: 718-454-3200