1124084942 NPI number — MS. ROXANNE MAE ROSE PHD

Table of content: NIKA NACHTSHEIM ROSEN (NPI 1295229250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124084942 NPI number — MS. ROXANNE MAE ROSE PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSE
Provider First Name:
ROXANNE
Provider Middle Name:
MAE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124084942
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 GRANDVIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEVILS LAKE
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58301-4123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-662-5590
Provider Business Mailing Address Fax Number:
701-665-3252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 GRANDVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEVILS LAKE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58301-4123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-662-5590
Provider Business Practice Location Address Fax Number:
701-665-3252
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  2096 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19124 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23117 . This is a "BC/BC" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 24043 . This is a "ND BC/BS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 181620900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 284K8DA . This is a "MN BC/BS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: N715569 . This is a "MEDICARE PTAN" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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