Provider Demographics
NPI:1902846165
Name:ROSE, QUENTIN (MD)
Entity Type:Individual
Prefix:
First Name:QUENTIN
Middle Name:
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:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-1359
Mailing Address - Country:US
Mailing Address - Phone:802-524-7100
Mailing Address - Fax:802-524-7021
Practice Address - Street 1:133 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:ST ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1726
Practice Address - Country:US
Practice Address - Phone:802-524-7100
Practice Address - Fax:802-524-7021
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT04200110322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011976Medicaid
VTP00256952OtherRAILROAD MEDICARE
VTP00256952OtherRAILROAD MEDICARE
VTVN3837Medicare ID - Type Unspecified