Provider Demographics
NPI:1326006776
Name:ROSEN, BRUCE M (NP)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:ROSEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8075 N SHADELAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2693
Practice Address - Country:US
Practice Address - Phone:317-621-8500
Practice Address - Fax:317-621-8501
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71000638A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01214655OtherRR MEDICARE PTAN
IN200184600Medicaid
IN898190D1Medicare ID - Type Unspecified
IN266180146Medicare PIN
INM400015091Medicare PIN
INS95652Medicare UPIN
INM400058302Medicare PIN