Basic Information
| Provider Information | |||||||||
| NPI: | 1104912450 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSENBERG | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 325 E EISENHOWER PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481083364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349367175 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 01/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 4301051728 | MI | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 4301051728 | MI | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207P00000X | 4301051728 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3069240 | 05 | MI | MEDICAID |