Healthcare Provider Details

I. General information

NPI: 1730527342
Provider Name (Legal Business Name): ROBERT M ROSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 SHARON RD STE 205
KING WILLIAM VA
23086-3344
US

IV. Provider business mailing address

1041 SHARON RD STE 205
KING WILLIAM VA
23086-3344
US

V. Phone/Fax

Practice location:
  • Phone: 804-769-3096
  • Fax: 804-769-3170
Mailing address:
  • Phone: 804-769-3096
  • Fax: 804-769-3170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101259659
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: