MEDICARE: ROSE MARIE SHAW-BULLOCK M.D.

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	207Q00000X	Family Medicine Physician	E0873	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790749943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSE MARIE SHAW-BULLOCK M.D.

Provider Business Mailing Address
First Line	:	400 W PERSHING BLVD
Second Line	:
City	:	N LITTLE ROCK
State	:	AR
Zip	:	72114-2146
Country	:	US
Telephone Number	:	501-771-7717
Fax Number	:	501-771-0550

Provider Business Practice Location Address
First Line	:	400 W PERSHING BLVD
Second Line	:
City	:	N LITTLE ROCK
State	:	AR
Zip	:	72114-2146
Country	:	US
Telephone Number	:	501-771-7717
Fax Number	:	501-771-0550

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	08/02/2010

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