Provider Demographics
NPI:1063890846
Name:ROSE, KATHERINE (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 HOLLYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7731
Mailing Address - Country:US
Mailing Address - Phone:843-496-4319
Mailing Address - Fax:
Practice Address - Street 1:9263 MEDICAL PLAZA DR STE E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-7112
Practice Address - Country:US
Practice Address - Phone:843-572-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC211020390200000X
SC82900207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program