Provider Demographics
NPI:1508864042
Name:ROSE, BERNARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:J
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 WILMINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-4001
Mailing Address - Country:US
Mailing Address - Phone:937-294-2555
Mailing Address - Fax:937-294-3211
Practice Address - Street 1:3017 WILMINGTON PIKE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-4001
Practice Address - Country:US
Practice Address - Phone:937-294-2555
Practice Address - Fax:937-294-3211
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052219R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0606259Medicaid
OHBE9266611Medicare ID - Type UnspecifiedGROUP
OHA17231Medicare UPIN
OH0606259Medicaid