Healthcare Provider Details

I. General information

NPI: 1962493304
Provider Name (Legal Business Name): RICHARD VINCENT HAUSROD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E RIVER ST
ELYRIA OH
44035-5902
US

IV. Provider business mailing address

498 BAY HILL DRIVE
AVON LAKE OH
44012
US

V. Phone/Fax

Practice location:
  • Phone: 440-329-7539
  • Fax:
Mailing address:
  • Phone: 440-930-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD427532
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.087318
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: