=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962493304
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD VINCENT HAUSROD MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 E RIVER ST
-----------------------------------------------------
City | ELYRIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44035-5902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-329-7539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 498 BAY HILL DRIVE
-----------------------------------------------------
City | AVON LAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-930-5040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MD427532
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 35.087318
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------