Basic Information
| Provider Information | |||||||||
| NPI: | 1316901069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | JANINE | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 235 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833261 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833261 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39866 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 20654-875 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 375525800 | 05 | MN | MEDICAID |