MEDICARE: NICHOLAS ROSENLICHT MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1376295022
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICHOLAS ROSENLICHT MD INC

Provider Business Mailing Address
First Line	:	1569 SOLANO AVE # 324
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94707-2116
Country	:	US
Telephone Number	:	510-558-3488
Fax Number	:	510-558-3488

Provider Business Practice Location Address
First Line	:	526 VINCENTE AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94707-1522
Country	:	US
Telephone Number	:	510-558-3488
Fax Number	:	855-558-3488

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICHOLAS ROSENLICHT
Credential	:	MD
Telephone Number	:	510-558-3488

Provider Enumeration Date	:	01/24/2022
Last Update Date	:	04/15/2022

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