MEDICARE: RICHARD ANTHONY ROSE D.P.M.

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	213E00000X	Podiatrist	688	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8970	OTHER		MIDLAND'S CHOICE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	58773	OTHER	IA	BC / BS

General Provider Information

NPI Number	:	1790775922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD ANTHONY ROSE D.P.M.

Provider Business Mailing Address
First Line	:	PO BOX 1687
Second Line	:
City	:	FAIRFIELD
State	:	IA
Zip	:	52556-0029
Country	:	US
Telephone Number	:	641-472-9371
Fax Number	:	641-472-9589

Provider Business Practice Location Address
First Line	:	202 E BRIGGS AVE
Second Line	:
City	:	FAIRFIELD
State	:	IA
Zip	:	52556-2925
Country	:	US
Telephone Number	:	641-472-9731
Fax Number	:	641-472-9589

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

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	10/02/2008

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