=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881158343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSE INTERNAL MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2019
-----------------------------------------------------
Last Update Date | 01/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2753 OBSERVATORY AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45208-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-871-7673
-----------------------------------------------------
Fax | 855-871-7673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2753 OBSERVATORY AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45208-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-871-7673
-----------------------------------------------------
Fax | 855-871-7673
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GEOFFREY A ROSE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 513-871-7673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------