Provider Demographics
NPI:1699716688
Name:ROSE, GINA L (MD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:L
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 789967
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-9967
Mailing Address - Country:US
Mailing Address - Phone:484-622-7395
Mailing Address - Fax:484-622-7399
Practice Address - Street 1:17 IRON BRIDGE DR STE 150
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-2042
Practice Address - Country:US
Practice Address - Phone:844-622-6320
Practice Address - Fax:484-622-6337
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD072494L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1313836OtherHIGHMARK BLUE SHIELD
PA2007117000OtherIBC - PC/KHPE
PA7696259OtherAETNA PPO
PA9201950OtherPHCS
PA1150744OtherKEYSTONE MERCY
PAP00260461OtherRRM
PA0018651570003Medicaid
PA10935099OtherCAQH ID#
PA2635215OtherAETNA HMO
PA7008842OtherCIGNA HMO/PPO
PA2007117000OtherAMERIHEALTH/INTERCOUNTY
PA1150744OtherKEYSTONE MERCY
PA0018651570003Medicaid