Provider Demographics
NPI:1437192796
Name:GILLIN, ROSE M (MD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:GILLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:M
Other - Last Name:ALVAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-2413
Mailing Address - Country:US
Mailing Address - Phone:574-534-4744
Mailing Address - Fax:574-537-1186
Practice Address - Street 1:400 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-2413
Practice Address - Country:US
Practice Address - Phone:574-534-4744
Practice Address - Fax:574-537-1186
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040912A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00090607OtherRAILROAD MEDICARE PIN
IN000000500568OtherANTHEM PIN
IN100354290Medicaid
226830CCMedicare PIN
IN000000500568OtherANTHEM PIN