Basic Information
| Provider Information | |||||||||
| NPI: | 1568844850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SEAGATE STE 800 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194795386 | ||||||||
| FaxNumber: | 4194795384 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 HARROUN RD STE 118 | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194795386 | ||||||||
| FaxNumber: | 4194795384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2015 | ||||||||
| LastUpdateDate: | 05/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50004359 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0137825 | 05 | OH | MEDICAID |