Healthcare Provider Details

I. General information

NPI: 1477536530
Provider Name (Legal Business Name): DAVID BERTRAND ROSE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 EUCLID AVE
GREENWOOD IN
46142-3613
US

IV. Provider business mailing address

CMR 427, BOX 2221
VICENZA VENETO
APO AE 09630
IT

V. Phone/Fax

Practice location:
  • Phone: 317-881-2958
  • Fax:
Mailing address:
  • Phone: 011390444583299
  • Fax: 011390444718210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1001247
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: