Provider Demographics
NPI:1215921978
Name:ROSE, KENNETH E (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
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 1:2410 AVALON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-3284
Mailing Address - Country:US
Mailing Address - Phone:256-386-0809
Mailing Address - Fax:256-383-8000
Practice Address - Street 1:2410 AVALON AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-3283
Practice Address - Country:US
Practice Address - Phone:256-386-0808
Practice Address - Fax:256-389-8904
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8461207R00000X
AL21078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL58815OtherMEDICARE
TX116304002Medicaid
TX85215NMedicare ID - Type UnspecifiedMEDICARE
TX116304002Medicaid
ALE354Medicare PIN