Healthcare Provider Details

I. General information

NPI: 1508864042
Provider Name (Legal Business Name): BERNARD J ROSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

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

III. Provider practice location address

3017 WILMINGTON PIKE
KETTERING OH
45429-4001
US

IV. Provider business mailing address

3017 WILMINGTON PIKE
KETTERING OH
45429-4001
US

V. Phone/Fax

Practice location:
  • Phone: 937-294-2555
  • Fax: 937-294-3211
Mailing address:
  • Phone: 937-294-2555
  • Fax: 937-294-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35052219R
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: