Provider Demographics
NPI:1376568568
Name:ROSE, ETHEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHEL
Middle Name:S
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1500 E. WOODROW WILSON DR
Mailing Address - Street 2:VAMC, 127
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5116
Mailing Address - Country:US
Mailing Address - Phone:601-364-1285
Mailing Address - Fax:601-364-1257
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:VAMC, 127
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-364-1285
Practice Address - Fax:601-364-1257
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS097362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology