Provider Demographics
NPI:1871541201
Name:ROSE, WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
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 1:5700 DARROW RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-5021
Mailing Address - Country:US
Mailing Address - Phone:330-656-5911
Mailing Address - Fax:330-656-5901
Practice Address - Street 1:214 SOUTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:KREMMLING
Practice Address - State:CO
Practice Address - Zip Code:80459-0399
Practice Address - Country:US
Practice Address - Phone:970-887-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.071985207P00000X
WV17964207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0994714Medicaid
OH310917085129OtherCARESOURCE
WV10054130OtherBWC
WV0045487000Medicaid
F63340Medicare UPIN