MEDICARE: MARY ANN ROSE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician	C43111	CA
2	2085R0001X	Radiation Oncology Physician	MD2015-0619	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114901469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ANN ROSE MD

Provider Business Mailing Address
First Line	:	455 SAINT MICHAELS DR
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-7601
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 SAINT MICHAELS DR
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-7601
Country	:	US
Telephone Number	:	505-913-8900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	07/06/2016

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Directions to “ MARY ANN ROSE MD” Practice Location

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