Basic Information
| Provider Information | |||||||||
| NPI: | 1902846165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | QUENTIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1359 | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054951359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025247100 | ||||||||
| FaxNumber: | 8025247021 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 FAIRFIELD ST | ||||||||
| Address2: | |||||||||
| City: | ST ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054781726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025247100 | ||||||||
| FaxNumber: | 8025247021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 05/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0420011032 | VT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1011976 | 05 | VT | MEDICAID | P00256952 | 01 | VT | RAILROAD MEDICARE | OTHER |