Provider Demographics
NPI:1396432779
Name:ROSE, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-1468
Mailing Address - Country:US
Mailing Address - Phone:803-570-3554
Mailing Address - Fax:
Practice Address - Street 1:808 F R HUFF DR
Practice Address - Street 2:
Practice Address - City:SAINT MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-1473
Practice Address - Country:US
Practice Address - Phone:803-570-3554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC002186146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic