Provider Demographics
NPI:1639180953
Name:ROSE, ROBERT A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
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 1:911 GORMAN AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3154
Mailing Address - Country:US
Mailing Address - Phone:304-636-2817
Mailing Address - Fax:
Practice Address - Street 1:911 GORMAN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3154
Practice Address - Country:US
Practice Address - Phone:304-636-2817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12337208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVA72084Medicare UPIN