Provider Demographics
NPI:1245276021
Name:ROSE, KEVIN G (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:G
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:320 RIVER PARK DR
Mailing Address - Street 2:SUITE 245
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6060
Mailing Address - Country:US
Mailing Address - Phone:801-375-7673
Mailing Address - Fax:801-375-7679
Practice Address - Street 1:374 E 400 S
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-1984
Practice Address - Country:US
Practice Address - Phone:801-491-8222
Practice Address - Fax:801-491-8365
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT5575028-1205208200000X, 2082S0099X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005778001Medicare ID - Type Unspecified
UTI18411Medicare UPIN