Provider Demographics
NPI:1225744022
Name:ROSE, MICHAEL (CT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8761 LINCOLNSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44149-1149
Mailing Address - Country:US
Mailing Address - Phone:440-876-3716
Mailing Address - Fax:
Practice Address - Street 1:3622 PROSPECT AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2704
Practice Address - Country:US
Practice Address - Phone:216-431-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2204523390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program