Provider Demographics
NPI:1568654929
Name:ROSE FAMILY MEDICINE CENTER PC
Entity Type:Organization
Organization Name:ROSE FAMILY MEDICINE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-584-7900
Mailing Address - Street 1:4545 E 9TH AVE STE #10
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220
Mailing Address - Country:US
Mailing Address - Phone:303-584-7900
Mailing Address - Fax:
Practice Address - Street 1:4545 E 9TH AVE STE # 10
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220
Practice Address - Country:US
Practice Address - Phone:303-584-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODA7385OtherRAILROAD MEDICARE
CO04023537Medicaid
COC248308Medicare PIN