Provider Demographics
NPI:1619120334
Name:ROSE, MATHEW J (DO)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:J
Last Name:ROSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130
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 1:11700 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4656
Practice Address - Country:US
Practice Address - Phone:317-962-3700
Practice Address - Fax:317-962-8800
Is Sole Proprietor?:No
Enumeration Date:2008-10-25
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004158A207P00000X
OH34-009941207P00000X
NC2011-00430207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201135580Medicaid
IN264430050Medicare PIN
IN201135580Medicaid