Provider Demographics
NPI:1275581944
Name:ROSE, GRACE WILLETT (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:WILLETT
Last Name:ROSE
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 1:701 EXPOSITION PLACE
Mailing Address - Street 2:STE. 218
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615
Mailing Address - Country:US
Mailing Address - Phone:919-791-2900
Mailing Address - Fax:919-845-2568
Practice Address - Street 1:701 EXPOSITION PLACE
Practice Address - Street 2:SUITE 218
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615
Practice Address - Country:US
Practice Address - Phone:919-791-2900
Practice Address - Fax:919-845-2568
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38424207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCR964AMedicare PIN
C39616Medicare UPIN
NC8973113Medicaid
NC214351GMedicare ID - Type Unspecified