Provider Demographics
NPI:1477544153
Name:ROSE, CHARLES HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HOWARD
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 1:2205 W SUDBURY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3737
Mailing Address - Country:US
Mailing Address - Phone:812-961-1540
Mailing Address - Fax:812-961-1535
Practice Address - Street 1:2205 W SUDBURY DR
Practice Address - Street 2:SUITE A
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3737
Practice Address - Country:US
Practice Address - Phone:812-961-1540
Practice Address - Fax:812-961-1535
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054413A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200398080Medicaid
INP00235073OtherRAILROAD MEDICARE
IN000000362446OtherBLUE CROSS BLUE SHIELD
IN200398080Medicaid
IN000000362446OtherBLUE CROSS BLUE SHIELD