Healthcare Provider Details

I. General information

NPI: 1578509345
Provider Name (Legal Business Name): MARY D ROUSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6640 INTECH BLVD SUITE 195
INDIANAPOLIS IN
46278-2011
US

IV. Provider business mailing address

6640 INTECH BLVD STE 195
INDIANAPOLIS IN
46278-2011
US

V. Phone/Fax

Practice location:
  • Phone: 317-295-0608
  • Fax: 317-295-0622
Mailing address:
  • Phone: 317-295-0608
  • Fax: 317-295-0622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number01040728
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: