Provider Demographics
NPI:1184697179
Name:FANNIE, ROSA
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:FANNIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 LIBERTY AVE
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4815 LIBERTY AVE
Practice Address - Street 2:SUITE 3100
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:412-621-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002226L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS63389Medicare UPIN
PA068729Medicare PIN