Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | 4301034077 | MI |
NPI | 1043214554 |
---|---|
Provider Name | Dr. Robert J Roosenberg |
First Address | Grand Rapids, MI 49525-6049 |
Second Address | Grand Rapids, MI 49525-6049 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2005 |
Last Update Date | 05/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1416722 | (05) | MI |
180015517 | MEDICARE RR (01) | MI |
180D148331 | BCBS (01) | MI |
B44771 | (02) |