Provider Demographics
NPI:1265408215
Name:ROSE, C MARK (DO)
Entity type:Individual
Prefix:DR
First Name:C MARK
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:C
Other - Middle Name:MARK
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:902 WOLLARD BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MO
Mailing Address - Zip Code:64085
Mailing Address - Country:US
Mailing Address - Phone:816-776-2201
Mailing Address - Fax:816-480-4515
Practice Address - Street 1:902 WOLLARD BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MO
Practice Address - Zip Code:64085
Practice Address - Country:US
Practice Address - Phone:816-776-2201
Practice Address - Fax:816-776-7678
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8G83207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242411015Medicaid
MO13238051OtherBCBS
E65687Medicare UPIN
MO242411015Medicaid
MOE556824Medicare PIN