Healthcare Provider Details

I. General information

NPI: 1679559892
Provider Name (Legal Business Name): GREGORY R ROUSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 BELMONT AVE
YOUNGSTOWN OH
44504-1006
US

IV. Provider business mailing address

PO BOX 20452
COLUMBUS OH
43220-0452
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-3768
  • Fax: 330-480-2062
Mailing address:
  • Phone: 614-457-8180
  • Fax: 614-583-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZM0300X
TaxonomyMedical Microbiology Physician
License Number35.060012
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number35.060012
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: