Provider Demographics
NPI:1568595874
Name:ROSE, CHARLES EDWARD III
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:ROSE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 NICHOLASVILLE RD
Mailing Address - Street 2:STE 602
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1404
Mailing Address - Country:US
Mailing Address - Phone:859-277-4005
Mailing Address - Fax:859-278-2507
Practice Address - Street 1:1720 NICHOLASVILLE RD
Practice Address - Street 2:STE 602
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1404
Practice Address - Country:US
Practice Address - Phone:859-277-4005
Practice Address - Fax:859-278-2507
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40916207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100020800Medicaid
KYP00396857OtherRR MEDICARE
KY234512Medicare PIN