Basic Information
| Provider Information | |||||||||
| NPI: | 1790823334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUTHERLAND | ||||||||
| FirstName: | ROSE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 UNION SCHOOL RD NW STE 1 | ||||||||
| Address2: | |||||||||
| City: | OCEAN ISLE BEACH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284697307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105790828 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1202 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9102512067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2007 | ||||||||
| LastUpdateDate: | 03/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 520 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213EP1101X | 520 | NC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
No ID Information.