Basic Information
| Provider Information | |||||||||
| NPI: | 1124231972 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4000 | ||||||||
| Address2: | |||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860424000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
| FaxNumber: | 9287376001 | ||||||||
| Practice Location | |||||||||
| Address1: | HOPI HEALTH CARE CENTER HIGWAY 264 | ||||||||
| Address2: | MM 388 | ||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860424000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
| FaxNumber: | 9287376001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD2006-0507 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | C63110 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 696809 | 05 | AZ | MEDICAID |