MEDICARE: NEW SMYRNA BEACH GYNECOLOGY & OBSTETRICS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	RN2893652	FL
2	207V00000X	Obstetrics & Gynecology Physician	ME32999	FL

General Provider Information

NPI Number	:	1245233725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW SMYRNA BEACH GYNECOLOGY & OBSTETRICS PA

Provider Business Mailing Address
First Line	:	603 S ORANGE ST
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7320
Country	:	US
Telephone Number	:	386-423-0333
Fax Number	:	386-423-0042

Provider Business Practice Location Address
First Line	:	603 S ORANGE ST
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7320
Country	:	US
Telephone Number	:	386-423-0333
Fax Number	:	386-423-0042

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JACOB DUDLEY ROUSE JR.
Credential	:	MD
Telephone Number	:	386-423-0333

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	09/07/2012

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