Healthcare Provider Details

I. General information

NPI: 1659365658
Provider Name (Legal Business Name): JOHN ROUSSEL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 11/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 NORTHGATE CT STE 101
NEW ALBANY IN
47150-6400
US

IV. Provider business mailing address

6601 ARBOR RIDGE DR
CRESTWOOD KY
40014-7745
US

V. Phone/Fax

Practice location:
  • Phone: 812-944-4263
  • Fax: 812-944-1166
Mailing address:
  • Phone: 502-931-9962
  • Fax: 502-561-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28152575A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number47452
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: