Basic Information
| Provider Information | |||||||||
| NPI: | 1215357991 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 SIXTH ST SW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447101702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303632319 | ||||||||
| FaxNumber: | 3305805509 | ||||||||
| Practice Location | |||||||||
| Address1: | 4860 FRANK AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304947099 | ||||||||
| FaxNumber: | 3304947099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2014 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35129488 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | H609640 | 01 | MEDICARE | OTHER |