Healthcare Provider Details

I. General information

NPI: 1700955184
Provider Name (Legal Business Name): KELLY L. ROSE M. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2541 EVANS ST STE 200
NEWBERRY SC
29108-2963
US

IV. Provider business mailing address

2541 EVANS ST STE 200
NEWBERRY SC
29108-2963
US

V. Phone/Fax

Practice location:
  • Phone: 803-276-0201
  • Fax:
Mailing address:
  • Phone: 803-924-7185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number003241
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number003241
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD28173
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: