Healthcare Provider Details

I. General information

NPI: 1770978108
Provider Name (Legal Business Name): GARY SAMUEL ROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 ROCKLAND RD
WILMINGTON DE
19803-3607
US

IV. Provider business mailing address

PO BOX 191
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-651-4200
  • Fax: 302-651-4945
Mailing address:
  • Phone: 302-651-6718
  • Fax: 301-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License NumberC1-0026244
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: