Provider Demographics
NPI:1174766497
Name:CARL H. ROSEN, M.D.
Entity type:Organization
Organization Name:CARL H. ROSEN, M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:H
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-287-0450
Mailing Address - Street 1:6373 BRANDENBURG RD
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-7534
Mailing Address - Country:US
Mailing Address - Phone:270-215-1036
Mailing Address - Fax:
Practice Address - Street 1:6373 BRANDENBURG RD
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-7534
Practice Address - Country:US
Practice Address - Phone:270-215-1036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000612641OtherANTHEM BCBS
KY50023039OtherPASSPORT HEALTH
KY64300205Medicaid
KY50023039OtherPASSPORT HEALTH
KY1974501Medicare PIN