Provider Demographics
NPI:1942597638
Name:MICHAEL, ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ROZA
Other - Middle Name:
Other - Last Name:SHIMSHILASHVILI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6433 99TH ST APT 4J
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3541
Mailing Address - Country:US
Mailing Address - Phone:347-453-4005
Mailing Address - Fax:
Practice Address - Street 1:9009 VAN WYCK EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2832
Practice Address - Country:US
Practice Address - Phone:718-206-5594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2603712084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03384916Medicaid
NYG400062667Medicare PIN