Provider Demographics
NPI:1750501425
Name:GEORGIA ROSE, CNM, INC
Entity Type:Organization
Organization Name:GEORGIA ROSE, CNM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:718-543-9000
Mailing Address - Street 1:123 W 93RD ST
Mailing Address - Street 2:#10C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7572
Mailing Address - Country:US
Mailing Address - Phone:212-864-3630
Mailing Address - Fax:212-864-3630
Practice Address - Street 1:285 W END AVE
Practice Address - Street 2:Y2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-2504
Practice Address - Country:US
Practice Address - Phone:212-531-2229
Practice Address - Fax:914-462-4409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000247367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS54929Medicare UPIN