Provider Demographics
NPI:1588658801
Name:ROSE, KENNETH D (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
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 1:303 S MAIN ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2189
Mailing Address - Country:US
Mailing Address - Phone:574-255-3888
Mailing Address - Fax:574-256-1632
Practice Address - Street 1:603 MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828
Practice Address - Country:US
Practice Address - Phone:541-426-3870
Practice Address - Fax:541-426-1901
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055738208600000X
OR28952208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200355260Medicaid
F42198Medicare UPIN
R156008Medicare PIN
164560IMedicare ID - Type Unspecified