Provider Demographics
NPI:1689668121
Name:ROSE, WALTER B (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:B
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 1:721 GLENWOOD DR
Mailing Address - Street 2:SUITE 550-WEST MEMORIAL MEDICAL BUILDING
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1106
Mailing Address - Country:US
Mailing Address - Phone:423-698-8692
Mailing Address - Fax:423-624-7813
Practice Address - Street 1:721 GLENWOOD DR
Practice Address - Street 2:SUITE 550-WEST MEMORIAL MEDICAL BUILDING
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1106
Practice Address - Country:US
Practice Address - Phone:423-698-8692
Practice Address - Fax:423-624-7813
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD16460174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3023956Medicare UPIN