Provider Demographics
NPI:1346205192
Name:ROSE, JOEL E (MD)
Entity type:Individual
Prefix:DR
First Name:JOEL
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 1:3618 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-3219
Mailing Address - Country:US
Mailing Address - Phone:212-926-2260
Mailing Address - Fax:
Practice Address - Street 1:3618 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-3219
Practice Address - Country:US
Practice Address - Phone:212-926-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039346E208000000X
NY298646208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016474430001Medicaid
PA546344Medicare PIN
PA0016474430001Medicaid