Provider Demographics
NPI:1922049824
Name:ROSE, RICHARD C III (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:ROSE
Suffix:III
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 1:1225 E WEISGARBER RD
Mailing Address - Street 2:STE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:
Practice Address - Street 1:1819 W CLINCH AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2434
Practice Address - Country:US
Practice Address - Phone:865-524-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13914207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110219283OtherRR MEDICARE PIN
TN3191275Medicaid
B59499Medicare UPIN
TN110219283OtherRR MEDICARE PIN
TN3714823Medicare ID - Type UnspecifiedLEGACY GROUP