=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518291384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN A ROUSH CST FA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2009
-----------------------------------------------------
Last Update Date | 09/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211 FAIRVIEW AVE
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-277-3209
-----------------------------------------------------
Fax | 307-472-1881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2211 FAIRVIEW AVE
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-277-3209
-----------------------------------------------------
Fax | 307-472-1881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------