Provider Demographics
NPI:1689899585
Name:ROBERTA EDMUNDSON ROSE MD INC
Entity Type:Organization
Organization Name:ROBERTA EDMUNDSON ROSE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:EDMUNDSON
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-269-5221
Mailing Address - Street 1:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46581-1222
Mailing Address - Country:US
Mailing Address - Phone:574-269-5221
Mailing Address - Fax:574-269-5580
Practice Address - Street 1:800 E CENTER ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3325
Practice Address - Country:US
Practice Address - Phone:574-269-5221
Practice Address - Fax:574-269-5580
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROBERTA EDMUNDSON ROSE M D INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-16
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029953A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0383940001Medicare NSC