=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962613737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDERIC ROSE, OD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 02/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72 MERRIMACK ST
-----------------------------------------------------
City | HAVERHILL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01830-6207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-374-0386
-----------------------------------------------------
Fax | 978-372-3631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 72 MERRIMACK ST
-----------------------------------------------------
City | HAVERHILL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01830-6207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-374-0386
-----------------------------------------------------
Fax | 978-372-3631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR.
-----------------------------------------------------
Name | DR. FREDERIC ROSE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 978-374-0386
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | MA2139
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------