Provider Demographics
NPI:1356776918
Name:ROSE, RILEY D (AG/ACNP)
Entity type:Individual
Prefix:MR
First Name:RILEY
Middle Name:D
Last Name:ROSE
Suffix:
Gender:M
Credentials:AG/ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N WABASH AVE
Mailing Address - Street 2:STE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2696
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1406 W BELLA DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5229
Practice Address - Country:US
Practice Address - Phone:765-660-7720
Practice Address - Fax:765-662-4493
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28161345A163WW0000X
IN741004600A363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000878522OtherANTHEM
IN201202120AMedicaid
IN000000878522OtherANTHEM