Provider Demographics
NPI:1063422285
Name:ROSE, KEITH (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
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:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-0034
Mailing Address - Country:US
Mailing Address - Phone:231-348-1995
Mailing Address - Fax:231-347-3223
Practice Address - Street 1:3916 CHARLEVOIX AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9722
Practice Address - Country:US
Practice Address - Phone:231-348-1995
Practice Address - Fax:231-347-3223
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064558208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2502410522OtherBCBS
MI5176947Medicaid
MI4692460-10Medicaid
F63705Medicare UPIN
MI0N70110Medicare PIN
MIP40400001Medicare PIN