Healthcare Provider Details

I. General information

NPI: 1457351348
Provider Name (Legal Business Name): JACQUELINE EVA ROSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5675 HARPERS FARM RD
COLUMBIA MD
21044-2268
US

IV. Provider business mailing address

5675 HARPERS FARM RD
COLUMBIA MD
21044-2268
US

V. Phone/Fax

Practice location:
  • Phone: 410-964-5423
  • Fax: 410-964-4332
Mailing address:
  • Phone: 410-964-5423
  • Fax: 410-964-4332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD0039059
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberMD30640
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: