Healthcare Provider Details

I. General information

NPI: 1790823334
Provider Name (Legal Business Name): ROSE S SOUTHERLAND DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2007
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 MEDICAL CENTER DR
WILMINGTON NC
28401-7307
US

IV. Provider business mailing address

25 UNION SCHOOL RD NW STE 1
OCEAN ISLE BEACH NC
28469-7307
US

V. Phone/Fax

Practice location:
  • Phone: 910-341-3300
  • Fax: 910-251-2067
Mailing address:
  • Phone: 910-579-0828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number520
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number520
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: