Healthcare Provider Details

I. General information

NPI: 1457905689
Provider Name (Legal Business Name): LISA DE ROSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 COLUMBUS AVE
BAY CITY MI
48708-6831
US

IV. Provider business mailing address

22101 MOROSS RD
DETROIT MI
48236-2148
US

V. Phone/Fax

Practice location:
  • Phone: 989-894-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4301514852
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4301514852
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: