Healthcare Provider Details

I. General information

NPI: 1568483261
Provider Name (Legal Business Name): VERNON R ROUSH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-5238
  • Fax: 740-441-8058
Mailing address:
  • Phone: 740-446-5238
  • Fax: 740-441-8058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number25495
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number189508
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: