Provider Demographics
NPI:1720189061
Name:ROSE MEDICAL GROUP
Entity Type:Organization
Organization Name:ROSE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:G33914
Authorized Official - Phone:323-221-6121
Mailing Address - Street 1:PO BOX 31250
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0250
Mailing Address - Country:US
Mailing Address - Phone:323-221-6121
Mailing Address - Fax:323-221-6120
Practice Address - Street 1:2400 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2219
Practice Address - Country:US
Practice Address - Phone:323-221-6121
Practice Address - Fax:323-221-6120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0014310Medicaid
CAE95396Medicare UPIN
CAGR0014310Medicaid
CA0746930001Medicare NSC