Provider Demographics
NPI:1609926856
Name:SAM ROSEMBERG MD PC
Entity type:Organization
Organization Name:SAM ROSEMBERG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-735-2441
Mailing Address - Street 1:41935 W 12 MILE RD
Mailing Address - Street 2:SUITE #308
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3111
Mailing Address - Country:US
Mailing Address - Phone:248-735-2441
Mailing Address - Fax:248-735-2447
Practice Address - Street 1:41935 W 12 MILE
Practice Address - Street 2:STE 308
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377
Practice Address - Country:US
Practice Address - Phone:248-735-2441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISR036293208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4816290Medicaid
MI4816290Medicaid
MIB43297Medicare UPIN
MI=========OtherTAX ID