MEDICARE: SHANNON 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	207R00000X	Internal Medicine Physician	G77178	CA
2	208000000X	Pediatrics Physician	G77178	CA
3	208M00000X	Hospitalist Physician	G77178	CA

General Provider Information

NPI Number	:	1932119450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON ROSE MD

Provider Business Mailing Address
First Line	:	275 E 200 S
Second Line	:	VISTA
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-2002
Country	:	US
Telephone Number	:	800-366-1884
Fax Number	:	866-360-6021

Provider Business Practice Location Address
First Line	:	275 E 200 S
Second Line	:	VISTA
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-4111
Country	:	US
Telephone Number	:	800-366-1884
Fax Number	:	866-360-6021

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	11/24/2009

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Directions to “ SHANNON ROSE MD” Practice Location

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