Provider Demographics
NPI:1124231972
Name:ROSEN, RUTH (MD)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:ROSEN
Suffix:
Gender:F
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:PO BOX 4000
Mailing Address - Street 2:
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042-4000
Mailing Address - Country:US
Mailing Address - Phone:928-737-6000
Mailing Address - Fax:928-737-6001
Practice Address - Street 1:HOPI HEALTH CARE CENTER HIGWAY 264
Practice Address - Street 2:MM 388
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042-4000
Practice Address - Country:US
Practice Address - Phone:928-737-6000
Practice Address - Fax:928-737-6001
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0507207Q00000X
CAC63110207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ696809Medicaid
AZ696809Medicaid
AZG20920Medicare UPIN