Individual
KENNETH D ROSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
603 MEDICAL PARKWAY, ENTERPRISE, OR 97828
(541) 426-3870
(541) 426-1901
Mailing address
303 S MAIN ST, SUITE 212, MISHAWAKA, IN 46544-2189
(574) 255-3888
(574) 256-1632
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
01055738
IN
208600000X
Surgery Physician
Primary
28952
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200355260
—
IN
Enumeration date
09/01/2005
Last updated
12/04/2012
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