Healthcare Provider Details

I. General information

NPI: 1558368811
Provider Name (Legal Business Name): JACK C ROSENFELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 N BROAD ST
LANSDALE PA
19446
US

IV. Provider business mailing address

826 N BROAD ST
LANSDALE PA
19446-2321
US

V. Phone/Fax

Practice location:
  • Phone: 215-855-1054
  • Fax: 215-855-3786
Mailing address:
  • Phone: 215-855-1054
  • Fax: 215-855-3786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD033781E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: