Provider Demographics
NPI:1669458154
Name:ROSE, RICHARD FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:FREDERICK
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 1:970 E WASHINGTON ST
Mailing Address - Street 2:STE 102
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3332
Mailing Address - Country:US
Mailing Address - Phone:330-722-1610
Mailing Address - Fax:330-722-1610
Practice Address - Street 1:970 E WASHINGTON ST
Practice Address - Street 2:STE 102
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3332
Practice Address - Country:US
Practice Address - Phone:330-722-1610
Practice Address - Fax:330-722-1610
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040545207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0454600Medicaid
OH0454600Medicaid
B73102Medicare UPIN