Provider Demographics
NPI:1902915713
Name:ROSENBERG, RALPH (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3828
Mailing Address - Country:US
Mailing Address - Phone:860-677-5533
Mailing Address - Fax:860-678-1305
Practice Address - Street 1:36 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3828
Practice Address - Country:US
Practice Address - Phone:860-677-5533
Practice Address - Fax:860-678-1305
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023114207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050388OtherCONNECTICARE
CT004245884Medicaid
CT010023114CT02OtherBC/BS
CT004245884Medicaid