Basic Information
Provider Information | |||||||||
NPI: | 1790881852 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSENBAUM | ||||||||
FirstName: | ALFRED | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 ROUTE 112 BLDG 4 | ||||||||
Address2: |   | ||||||||
City: | PORT JEFFERSON STATION | ||||||||
State: | NY | ||||||||
PostalCode: | 117768055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317513000 | ||||||||
FaxNumber: | 6315096559 | ||||||||
Practice Location | |||||||||
Address1: | 1421 3RD AVE | ||||||||
Address2: | FIRST FLOOR | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100281802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127445538 | ||||||||
FaxNumber: | 2127444767 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2006 | ||||||||
LastUpdateDate: | 01/31/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/31/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 116442 | NY | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0202X | 116442 | NY | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 1790881852 | 01 |   | NPI | OTHER |