=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083098248
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW GRANT ROSENZWEIG D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2015
-----------------------------------------------------
Last Update Date | 09/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 94 OLD SHORT HILLS RD
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039-5672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-322-5938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 94 OLD SHORT HILLS RD
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039-5672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-322-5938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 25MB11614700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------