Provider Demographics
NPI:1316931959
Name:ROSEN, CARL H (MD)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:H
Last Name:ROSEN
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 1:6373 BRANDENBURG RD
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-7534
Mailing Address - Country:US
Mailing Address - Phone:270-215-1036
Mailing Address - Fax:270-844-4654
Practice Address - Street 1:6373 BRANDENBURG RD
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-7534
Practice Address - Country:US
Practice Address - Phone:270-215-1036
Practice Address - Fax:270-844-4654
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000612653OtherANTHEMBCBS
KY10810680OtherCAQH
KY000000476600OtherANTHEM BLUE CROSS AND BLUE SHIELD
KY64300205Medicaid
KY50023040OtherPASSPORT HEALTH
KY00023002Medicare PIN
KY1974501Medicare PIN
KY64300205Medicaid