Provider Demographics
NPI:1326015900
Name:ROSE, SHANE J (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:J
Last Name:ROSE
Suffix:
Gender:M
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 2303
Mailing Address - Street 2:DEPT 163
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206
Mailing Address - Country:US
Mailing Address - Phone:952-542-8553
Mailing Address - Fax:952-513-6880
Practice Address - Street 1:11900 N PENNSYLVANIA STREET
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4694
Practice Address - Country:US
Practice Address - Phone:317-846-0717
Practice Address - Fax:317-846-0557
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049705A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200250980Medicaid
H01413Medicare UPIN
IN522760TMedicare ID - Type Unspecified