Provider Demographics
NPI:1558307892
Name:ROSE, PHILIP M (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:M
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:PO BOX 1750
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97528-0148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5554
Practice Address - Country:US
Practice Address - Phone:541-472-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD165452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR053640Medicaid
OR053640Medicaid
R102282Medicare PIN