=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629117916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILIN ROSA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 06/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 655 W 8TH STREET DEPARTMENT OF PATHOLOGY
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-244-5326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 44008 UFJP PROVIDER ENROLLMENT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32231-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZC0500X
-----------------------------------------------------
Taxonomy Name | Cytopathology Physician
-----------------------------------------------------
License Number | 40064
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZC0500X
-----------------------------------------------------
Taxonomy Name | Cytopathology Physician
-----------------------------------------------------
License Number | ME98521
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------