Healthcare Provider Details

I. General information

NPI: 1255623807
Provider Name (Legal Business Name): BRANDON KEITH ROSE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE FL 4
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

3200 MACCORKLE SEAVE B16
CHARLESTON WV
25304-1227
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5590
  • Fax: 304-388-8238
Mailing address:
  • Phone: 304-388-5848
  • Fax: 304-388-9654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2642
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2642
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: