=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518920875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL E ROOSE DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2006
-----------------------------------------------------
Last Update Date | 08/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 N STATE ST
-----------------------------------------------------
City | REED CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49677-1089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-832-9533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 N PATTERSON AVE
-----------------------------------------------------
City | REED CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-832-9533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 5101006576
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------