Provider Demographics
NPI:1962490904
Name:ROSE, MICHAL GILLIAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAL
Middle Name:GILLIAN
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-2770
Mailing Address - Country:US
Mailing Address - Phone:203-937-3421
Mailing Address - Fax:203-937-3803
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-937-3421
Practice Address - Fax:203-937-3803
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033348207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001333492Medicaid
CT001333492Medicaid