Provider Demographics
NPI:1497721245
Name:ROOSE, ELLEN B (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
Last Name:ROOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4949 WESTOWN PKWY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6702
Mailing Address - Country:US
Mailing Address - Phone:515-223-5466
Mailing Address - Fax:515-223-5405
Practice Address - Street 1:4949 WESTOWN PKWY
Practice Address - Street 2:SUITE 140
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-6702
Practice Address - Country:US
Practice Address - Phone:515-223-5466
Practice Address - Fax:515-223-5405
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26536207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA26536OtherWELLMARK BCBS
IA0045666Medicaid
IA0045666Medicaid
IAA03483Medicare UPIN