Healthcare Provider Details

I. General information

NPI: 1346240231
Provider Name (Legal Business Name): MYRA E ROSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 08/09/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

720 WESTVIEW DRIVE SW HARRIS BLDG., 100-A
ATLANTA GA
30310
US

V. Phone/Fax

Practice location:
  • Phone: 404-756-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number018727
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number018727
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: