Provider Demographics
NPI:1194796912
Name:ROSE MEDICAL ASSSOCIATES PC
Entity type:Organization
Organization Name:ROSE MEDICAL ASSSOCIATES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:COPPOLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:724-349-8311
Mailing Address - Street 1:15 SOUTH 8TH STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701
Mailing Address - Country:US
Mailing Address - Phone:724-349-8311
Mailing Address - Fax:724-349-8331
Practice Address - Street 1:15 SOUTH 8TH STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701
Practice Address - Country:US
Practice Address - Phone:724-349-8311
Practice Address - Fax:724-349-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019377E207R00000X
PAMD19405E207R00000X
PAMD040660E207R00000X
PAMD069735L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012162760003OtherMA
PA0010119580003OtherMA
838362OtherBS
PA0012170590003OtherMA
PA0075777490003OtherMA
A72365Medicare UPIN
PA0012162760003OtherMA
PA0075777490003OtherMA
PA120812Q14Medicare ID - Type Unspecified
C30273Medicare UPIN
PA0010119580003OtherMA
PA0012170590003OtherMA
PA486313Q14Medicare ID - Type Unspecified