Provider Demographics
NPI:1124059548
Name:ROSE, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
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:PO BOX 2065
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98111-2065
Mailing Address - Country:US
Mailing Address - Phone:888-828-3195
Mailing Address - Fax:
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-472-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14469207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D86800OtherGROUP HEALTH
OR068783Medicaid
055542001OtherBCBS
57597OtherWA L&I
CAXPY186301Medicaid
D86800OtherPROVIDENCE
WA8202269Medicaid
930027259OtherRAILROAD MEDICARE
JM9461OtherPACC
930027259OtherRAILROAD MEDICARE
OR068783Medicaid