Provider Demographics
NPI:1750354106
Name:ROSE, EDWARD A (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:970 ALTRURIA DR
Mailing Address - Street 2:APT. 421
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-0167
Mailing Address - Country:US
Mailing Address - Phone:707-931-4636
Mailing Address - Fax:
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:SUITE 130
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-393-4152
Practice Address - Fax:707-393-4558
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG88082207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104469102Medicaid
N64500002Medicare ID - Type Unspecified
MI104469102Medicaid