Provider Demographics
NPI:1538383807
Name:T ROSE MD, PA
Entity type:Organization
Organization Name:T ROSE MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:T
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-628-2603
Mailing Address - Street 1:21 GREEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-9070
Mailing Address - Country:US
Mailing Address - Phone:347-628-2603
Mailing Address - Fax:732-462-0868
Practice Address - Street 1:710 TENNENT RD
Practice Address - Street 2:SUITE#204
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3161
Practice Address - Country:US
Practice Address - Phone:732-972-1570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA05615100261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0044962Medicaid
NJ083735Medicare ID - Type Unspecified
NJ0044962Medicaid