Healthcare Provider Details

I. General information

NPI: 1134230501
Provider Name (Legal Business Name): LAURIE A ROUSSEAU DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 STATE ROUTE 113 E
BERLIN HEIGHTS OH
44814-9348
US

IV. Provider business mailing address

1031 PIERCE STREET SUITE D
SANDUSKY OH
44870
US

V. Phone/Fax

Practice location:
  • Phone: 419-588-2975
  • Fax: 419-558-2958
Mailing address:
  • Phone: 419-557-5541
  • Fax: 419-557-5542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101014619
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: