Basic Information
Provider Information | |||||||||
NPI: | 1447272323 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSE | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | SUN KYU KWAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 FOOTHILL DR | ||||||||
Address2: |   | ||||||||
City: | SLC | ||||||||
State: | UT | ||||||||
PostalCode: | 841480001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015821565 | ||||||||
FaxNumber: | 8015842576 | ||||||||
Practice Location | |||||||||
Address1: | 500 FOOTHILL DR | ||||||||
Address2: |   | ||||||||
City: | SLC | ||||||||
State: | UT | ||||||||
PostalCode: | 841480001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015821565 | ||||||||
FaxNumber: | 8015842576 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2006 | ||||||||
LastUpdateDate: | 01/11/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5756670-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD60136118 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 9370535 | 01 | WA | AETNA | OTHER | 1447272323 | 05 | WA |   | MEDICAID | 0211RO | 01 | WA | REGENCE | OTHER | 0260516 | 01 | WA | L&I AND CRIME VICTIMS | OTHER | 8567380 | 05 | WA |   | MEDICAID |