Healthcare Provider Details

I. General information

NPI: 1063461416
Provider Name (Legal Business Name): GLENN S. ROUSH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 THE 25 WAY NE
ALBUQUERQUE NM
87109-5888
US

IV. Provider business mailing address

121 GREYSTONE DR
HILLSBORO OH
45133-1537
US

V. Phone/Fax

Practice location:
  • Phone: 505-332-6921
  • Fax: 256-382-6455
Mailing address:
  • Phone: 937-393-6959
  • Fax: 937-393-6959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number79-83
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: