Provider Demographics
NPI:1528286283
Name:ROBERTA EDMUNDSON ROSE M D INC
Entity type:Organization
Organization Name:ROBERTA EDMUNDSON ROSE M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:EDMUNDSON
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-269-5221
Mailing Address - Street 1:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46581-1222
Mailing Address - Country:US
Mailing Address - Phone:574-269-5221
Mailing Address - Fax:574-269-5580
Practice Address - Street 1:800 E CENTER ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3325
Practice Address - Country:US
Practice Address - Phone:574-269-5221
Practice Address - Fax:574-269-5580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IN01029953A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
128983500OtherDEPARTMENT OF LABOR FECA
DN2076Medicare PIN
IN451840Medicare PIN
0383940001Medicare NSC