Provider Demographics
NPI:1568756930
Name:BROUGHTON, ROSE MAE (MD)
Entity Type:Individual
Prefix:MISS
First Name:ROSE MAE
Middle Name:
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROSE MAE
Other - Middle Name:
Other - Last Name:TANTOCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 ARMORY RD
Practice Address - Street 2:
Practice Address - City:DELPHI
Practice Address - State:IN
Practice Address - Zip Code:46923-1910
Practice Address - Country:US
Practice Address - Phone:765-564-2777
Practice Address - Fax:765-564-6580
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069257A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000898754OtherANTHEM PROVIDER NUMBER
IN201039510Medicaid
IN201039510Medicaid
INP01420946Medicare PIN
IN000000898754OtherANTHEM PROVIDER NUMBER