=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255513842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SVETLANA ROZENBERG PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2007
-----------------------------------------------------
Last Update Date | 01/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 MCCARTER HWY
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07114-2562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-643-4969
-----------------------------------------------------
Fax | 973-643-3657
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 375 MCCARTER HWY
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07114-2562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-643-8601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 25MP00096300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------