Provider Demographics
NPI:1558304196
Name:ROSE, HARRIS SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:HARRIS
Middle Name:SAMUEL
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 1:11652 JOLLYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-3935
Mailing Address - Country:US
Mailing Address - Phone:512-551-0375
Mailing Address - Fax:512-551-0634
Practice Address - Street 1:11652 JOLLYVILLE RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-3935
Practice Address - Country:US
Practice Address - Phone:512-551-0375
Practice Address - Fax:512-551-0634
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4488207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6523740001Medicare NSC
8F3849Medicare PIN
164150Medicare UPIN