1194796912 NPI number — ROSE MEDICAL ASSSOCIATES PC

Table of content: (NPI 1194796912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194796912 NPI number — ROSE MEDICAL ASSSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSE MEDICAL ASSSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1194796912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 SOUTH 8TH STREET
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
INDIANA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-349-8311
Provider Business Mailing Address Fax Number:
724-349-8331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 SOUTH 8TH STREET
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
INDIANA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-349-8311
Provider Business Practice Location Address Fax Number:
724-349-8311
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COPPOLO
Authorized Official First Name:
BERNARD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
724-349-8311

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD019377E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: MD19405E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MD040660E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MD069735L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0012162760003 . This is a "MA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0010119580003 . This is a "MA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 838362 . This is a "BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0012170590003 . This is a "MA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0075777490003 . This is a "MA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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