Provider Demographics
NPI:1811911209
Name:LOVELL-ROSE, STEPHANIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LOVELL-ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 AMADOR AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2602
Mailing Address - Country:US
Mailing Address - Phone:631-987-9603
Mailing Address - Fax:631-868-8018
Practice Address - Street 1:1160 AMADOR AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2602
Practice Address - Country:US
Practice Address - Phone:631-987-9603
Practice Address - Fax:510-868-8018
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228857207P00000X
CAC53689207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0082QWS101Medicare PIN