Provider Demographics
NPI:1255395588
Name:ROSE, HENRY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:JOHN
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BLAUVELT AVE
Mailing Address - Street 2:
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423
Mailing Address - Country:US
Mailing Address - Phone:201-444-1493
Mailing Address - Fax:
Practice Address - Street 1:120 BLAUVELT AVE
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423
Practice Address - Country:US
Practice Address - Phone:201-444-1493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03807400207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3269205Medicaid
NJA52152Medicare UPIN
NJ453673Medicare PIN