Healthcare Provider Details

I. General information

NPI: 1336179340
Provider Name (Legal Business Name): JASON G. ROSENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N LAKE DR STE 300
MILWAUKEE WI
53211-4528
US

IV. Provider business mailing address

1121 E NORTH AVE
MILWAUKEE WI
53212-3515
US

V. Phone/Fax

Practice location:
  • Phone: 414-298-7100
  • Fax: 414-298-7101
Mailing address:
  • Phone: 414-267-6502
  • Fax: 414-267-3892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number44786
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number44786
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: