Provider Demographics
NPI:1770787509
Name:ROSE, MICHAEL P (LAT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:ROSE
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3534 N WILTON AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:735 HIGHGROVE PL
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2520
Practice Address - Country:US
Practice Address - Phone:815-226-4365
Practice Address - Fax:815-226-4589
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960019732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer