MEDICARE: MS. AVA ROSE 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	207R00000X	Internal Medicine Physician	50321	AZ

General Provider Information

NPI Number	:	1881968733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AVA ROSE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 617
Second Line	:
City	:	SOMERTON
State	:	AZ
Zip	:	85350-0617
Country	:	US
Telephone Number	:	928-315-7910
Fax Number	:	928-722-6113

Provider Business Practice Location Address
First Line	:	151 S OAK AVE STE 2
Second Line	:
City	:	SAN LUIS
State	:	AZ
Zip	:	85336-0756
Country	:	US
Telephone Number	:	928-662-0414
Fax Number	:	928-722-6113

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

Provider Enumeration Date	:	02/23/2012
Last Update Date	:	05/28/2021

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