Healthcare Provider Details

I. General information

NPI: 1528286283
Provider Name (Legal Business Name): ROBERTA EDMUNDSON ROSE M D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CENTER ST
WARSAW IN
46580-3325
US

IV. Provider business mailing address

PO BOX 1222
WARSAW IN
46581-1222
US

V. Phone/Fax

Practice location:
  • Phone: 574-269-5221
  • Fax: 574-269-5580
Mailing address:
  • Phone: 574-269-5221
  • Fax: 574-269-5580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number01029953A
License Number StateIN

VIII. Authorized Official

Name: ROBERTA EDMUNDSON ROSE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 574-269-5221