=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215806864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN BRIAN ROSE PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2025
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 MAIN ST
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48111-2650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-489-6440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1476 MARIAN AVE
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48103-5728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-489-6440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | 5502005370
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------