=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942550868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GILLIAN KARA ROSE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2012
-----------------------------------------------------
Last Update Date | 09/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 GARDEN CITY PLZ
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-747-9030
-----------------------------------------------------
Fax | 516-877-0998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 WENMORE RD
-----------------------------------------------------
City | COMMACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11725-1638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-830-1829
-----------------------------------------------------
Fax | 631-543-2608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 566357111
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 354266091
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 354265091
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 501257111
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------