Provider Demographics
NPI:1487652178
Name:ROSE, GREGORY CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CHARLES
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 1:2800 BLUE RIDGE RD STE 550
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6777
Mailing Address - Country:US
Mailing Address - Phone:919-787-5380
Mailing Address - Fax:
Practice Address - Street 1:2800 BLUE RIDGE RD STE 400
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6477
Practice Address - Country:US
Practice Address - Phone:919-787-5380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31374207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-73294Medicaid
NC210020BMedicare PIN
NCC25774Medicare UPIN