Provider Demographics
NPI:1609286509
Name:ROOSE, BENJAMIN P (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:P
Last Name:ROOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1105 SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2386
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:927 S CARMEL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2547
Practice Address - Country:US
Practice Address - Phone:231-876-3876
Practice Address - Fax:231-775-1115
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036.150773208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery