Provider Demographics
NPI:1538148218
Name:ROSE, WARREN WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:WILLIAM
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-0040
Mailing Address - Country:US
Mailing Address - Phone:508-909-7799
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTH ST STE 108
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-764-6966
Practice Address - Fax:508-764-2457
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055514208600000X
MA281234208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0796143Medicaid
OH0822842OtherMEDICARE ID
OH0822846OtherMEDICARE ID
OH0822844OtherMEDICARE ID
OH0822841OtherMEDICARE ID
OH0822843OtherMEDICARE ID
OH0796143Medicaid