Provider Demographics
NPI:1376593715
Name:ROSE, SUSAN P (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6820 PARKDALE PL
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-6601
Practice Address - Country:US
Practice Address - Phone:317-297-7773
Practice Address - Fax:317-297-3619
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01037465A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100131110Medicaid
INE33287Medicare UPIN
IN715530DDMedicare PIN
INM400064934Medicare PIN