Provider Demographics
NPI:1407857352
Name:ROSE, CARROLL EVERETT (MD)
Entity Type:Individual
Prefix:MR
First Name:CARROLL
Middle Name:EVERETT
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 1679
Mailing Address - Street 2:
Mailing Address - City:NEW TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37825-1679
Mailing Address - Country:US
Mailing Address - Phone:423-626-4288
Mailing Address - Fax:423-626-1101
Practice Address - Street 1:1610 TAZEWELL RD
Practice Address - Street 2:STE 301
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879-3600
Practice Address - Country:US
Practice Address - Phone:423-626-4288
Practice Address - Fax:423-626-1101
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7511208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528259Medicaid
TN1528259Medicaid
KYK050031Medicare PIN
TN103I023616Medicare PIN