Provider Demographics
NPI:1578649224
Name:ROSE-INNES, ANDREW PETER (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:PETER
Last Name:ROSE-INNES
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 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-488-2424
Practice Address - Fax:503-229-7105
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1654942084N0400X
WAMD000437262084N0400X
ORMD1506642084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
318500OtherINTERNAL ID-MOTOR VEHICLE ID
WAP00228213OtherRAIL ROAD MEDICARE
WA8395964Medicaid
OR500616010Medicaid
318500OtherINTERNAL ID-MOTOR VEHICLE ID
WA8395964Medicaid
ORP01148985Medicare PIN
WA8850008Medicare PIN
8804679Medicare ID - Type Unspecified