MEDICARE: MR. ED ROSA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	C.2103081-TRNE	OH

General Provider Information

NPI Number	:	1114511649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ED ROSA

Provider Business Mailing Address
First Line	:	1928 W 44TH ST UPPR
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44113-3259
Country	:	US
Telephone Number	:	440-225-2371
Fax Number	:

Provider Business Practice Location Address
First Line	:	22639 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44117-1622
Country	:	US
Telephone Number	:	216-404-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2021
Last Update Date	:	02/25/2021

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Directions to “ MR. ED ROSA ” Practice Location

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