Provider Demographics
NPI:1154300119
Name:ROSE, AMY T (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:T
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7202 GLEN FOREST DR STE 200
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3780
Mailing Address - Country:US
Mailing Address - Phone:804-673-2024
Mailing Address - Fax:804-673-1796
Practice Address - Street 1:10710 MIDLOTHIAN TPKE STE 138
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4766
Practice Address - Country:US
Practice Address - Phone:804-348-2814
Practice Address - Fax:855-815-0304
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236217208600000X
VA0101-236217208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010063167Medicaid
VAC01120OtherGROUP PTAN
VA004495552Medicare ID - Type Unspecified