Provider Demographics
NPI:1841679107
Name:ROSE, BENJAMIN TYLER (DO)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:TYLER
Last Name:ROSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W SHARON RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4137
Mailing Address - Country:US
Mailing Address - Phone:513-771-7213
Mailing Address - Fax:513-771-4356
Practice Address - Street 1:212 W SHARON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-4137
Practice Address - Country:US
Practice Address - Phone:513-771-7213
Practice Address - Fax:513-771-4356
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012630208M00000X, 207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0280722Medicaid
OH0146582Medicaid