Basic Information
| Provider Information | |||||||||
| NPI: | 1710081294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSTAN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 PAGE RD | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
| FaxNumber: | 9102353421 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 PAGE RD | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
| FaxNumber: | 9102353398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 05/29/2015 | ||||||||
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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 | 174400000X | 17600 | NC | N | Other Service Providers | Specialist | 207ND0900X | 17600 | NC | Y | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 73446 | 01 | NC | BLUE CROSS | OTHER | 8973446 | 05 | NC | MEDICAID | FH2000385 | 01 | NC | FIRSTCAROLIINACARE | OTHER | P01310778 | 01 | NC | PALMETTO GBA RAILROAD MCR | OTHER | Q17600 | 01 | SC | SC MEDICAID | OTHER |