Provider Demographics
NPI:1790823334
Name:SOUTHERLAND, ROSE S (DPM)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:S
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 UNION SCHOOL RD NW STE 1
Mailing Address - Street 2:
Mailing Address - City:OCEAN ISLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28469-7307
Mailing Address - Country:US
Mailing Address - Phone:910-579-0828
Mailing Address - Fax:
Practice Address - Street 1:1202 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7307
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:910-251-2067
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC520213ES0103X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6140290001Medicare NSC