Provider Demographics
NPI:1093784886
Name:ROSE TREE MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:ROSE TREE MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:610-891-9277
Mailing Address - Street 1:1098 W BALTIMORE PIKE
Mailing Address - Street 2:SUITE 3101 OUTPATIENT PAVILION
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5139
Mailing Address - Country:US
Mailing Address - Phone:610-891-9277
Mailing Address - Fax:610-891-7778
Practice Address - Street 1:1098 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 3101 OUTPATIENT PAVILION
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5139
Practice Address - Country:US
Practice Address - Phone:610-891-9277
Practice Address - Fax:610-891-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012914240001Medicaid
PA1012914240002Medicaid
PADD7693OtherRAIL ROAD
PADD7693Medicare Oscar/Certification
PA1012914240001Medicaid