Healthcare Provider Details

I. General information

NPI: 1184609034
Provider Name (Legal Business Name): MARTIN PHILLIP ROSE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 OAKINGTON ST
APG MD
21005-5131
US

IV. Provider business mailing address

4841 SEVEN TRAILS CIR
ABERDEEN MD
21001-2628
US

V. Phone/Fax

Practice location:
  • Phone: 410-278-5356
  • Fax:
Mailing address:
  • Phone: 410-278-5356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1042882
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: