Healthcare Provider Details

I. General information

NPI: 1083613541
Provider Name (Legal Business Name): TARA KERN ROSE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: TARA RUTH KERN O.D.

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 CENTURY III MALL
WEST MIFFLIN PA
15122
US

IV. Provider business mailing address

121 GOLFVIEW DR
MC MURRAY PA
15317-5327
US

V. Phone/Fax

Practice location:
  • Phone: 412-655-1988
  • Fax: 412-653-6460
Mailing address:
  • Phone: 724-969-6936
  • Fax: 724-969-6936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: