Provider Demographics
NPI:1700955184
Name:ROSE, KELLY L (M D)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:ROSE
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 EVANS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-2963
Mailing Address - Country:US
Mailing Address - Phone:803-924-7185
Mailing Address - Fax:
Practice Address - Street 1:2541 EVANS ST STE 200
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2963
Practice Address - Country:US
Practice Address - Phone:803-276-0201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003241207ZF0201X, 207ZP0102X
SCMD28173207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology