Provider Demographics
NPI:1780876409
Name:JOSE P DELA ROSA MD
Entity type:Organization
Organization Name:JOSE P DELA ROSA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DELA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-779-9960
Mailing Address - Street 1:203 PALUSTER STREET
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601
Mailing Address - Country:US
Mailing Address - Phone:231-779-9960
Mailing Address - Fax:231-779-8945
Practice Address - Street 1:203 PALUSTER STREET
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601
Practice Address - Country:US
Practice Address - Phone:231-779-9960
Practice Address - Fax:231-779-8945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052242207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICK6820OtherRAILROAD MEDICARE
MICK6820OtherRAILROAD MEDICARE
C30044Medicare UPIN
H46642Medicare UPIN