=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124099684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY A. ROSEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2006
-----------------------------------------------------
Last Update Date | 04/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19550 E 39TH ST S STE 400
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64057-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-698-8290
-----------------------------------------------------
Fax | 816-698-8291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19550 E 39TH ST S STE 400
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64057-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-698-8290
-----------------------------------------------------
Fax | 816-698-8291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | R7864
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 04-29598
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------