Provider Demographics
NPI:1104901347
Name:ROSE, COLIN A (MD)
Entity type:Individual
Prefix:DR
First Name:COLIN
Middle Name:A
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:PO BOX 671
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-0671
Mailing Address - Country:US
Mailing Address - Phone:304-645-4043
Mailing Address - Fax:304-645-4713
Practice Address - Street 1:202 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1334
Practice Address - Country:US
Practice Address - Phone:304-645-4043
Practice Address - Fax:304-645-4713
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV177102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1058352OtherWV WORKERS COMP
WV0120309000Medicaid
WV010097983OtherFEDERAL WKRS COMP/BL
462502OtherANTHEM BCBS
55073865301OtherCHAMPUS
WV300126637OtherRAILROAD MCARE
WV001722063OtherMTN STATE BCBS
WV288546OtherMAMSI
WV010097983OtherFEDERAL WKRS COMP/BL
F90526Medicare UPIN
WV0120309000Medicaid