Provider Demographics
NPI:1134596570
Name:KENNETH M. ROSE, M.D.,
Entity type:Organization
Organization Name:KENNETH M. ROSE, M.D.,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-888-7773
Mailing Address - Street 1:300 E 56TH ST
Mailing Address - Street 2:SUITE #10C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4136
Mailing Address - Country:US
Mailing Address - Phone:212-888-7773
Mailing Address - Fax:212-421-7930
Practice Address - Street 1:170 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2612
Practice Address - Country:US
Practice Address - Phone:212-888-7773
Practice Address - Fax:212-421-7930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186699146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1710033584Medicare NSC