Provider Demographics
NPI:1548277452
Name:ROSE MEDICAL GROUP LTD
Entity type:Organization
Organization Name:ROSE MEDICAL GROUP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-257-1490
Mailing Address - Street 1:4600 MEMORIAL DR
Mailing Address - Street 2:SUITE 480 MEDICAL BLDG #2
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5366
Mailing Address - Country:US
Mailing Address - Phone:618-257-1490
Mailing Address - Fax:618-222-6819
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:SUITE 480 MEDICAL BLDG #2
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5366
Practice Address - Country:US
Practice Address - Phone:618-257-1490
Practice Address - Fax:618-222-6819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4736207RR0500X
IL207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8225530OtherIL BLUE CROSS BLUE SHIELD
C43645Medicare UPIN
IL566410Medicare ID - Type Unspecified