Basic Information
| Provider Information | |||||||||
| NPI: | 1114371762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | SCOTT | ||||||||
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| Mailing Information | |||||||||
| Address1: | WAKE FOREST BAPTIST HEALTH MEDICAL CENTER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199661459 | ||||||||
| FaxNumber: | 9198439355 | ||||||||
| Practice Location | |||||||||
| Address1: | WAKE FOREST BAPTIST HEALTH MEDICAL CENTER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162718 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2016 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.