Provider Demographics
NPI:1588832554
Name:DR. MARK ROSE DPM
Entity Type:Organization
Organization Name:DR. MARK ROSE DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:617-361-9776
Mailing Address - Street 1:67 UNION ST
Mailing Address - Street 2:STE 304
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-7700
Mailing Address - Country:US
Mailing Address - Phone:617-361-9776
Mailing Address - Fax:617-361-1254
Practice Address - Street 1:67 UNION ST
Practice Address - Street 2:STE 304
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-7700
Practice Address - Country:US
Practice Address - Phone:617-361-9776
Practice Address - Fax:617-361-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1800213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY70826Medicare PIN
MA1061550001Medicare NSC