Healthcare Provider Details

I. General information

NPI: 1558546739
Provider Name (Legal Business Name): MARK A.ROSEN MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 FASHION BLVD. SUITE 100
MURRAY UT
84107
US

IV. Provider business mailing address

5911 FASHION BLVD. SUITE 100
MURRAY UT
84107
US

V. Phone/Fax

Practice location:
  • Phone: 801-269-1333
  • Fax: 801-261-2288
Mailing address:
  • Phone: 801-269-1333
  • Fax: 801-261-2288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number173613
License Number StateUT

VIII. Authorized Official

Name: DR. MARK A. ROSEN
Title or Position: DOCTOR
Credential: MD
Phone: 801-269-1333