MEDICARE: KELLEY HOWARD ROUSE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	2006-01097	NC

General Provider Information

NPI Number	:	1245349497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY HOWARD ROUSE MD

Provider Business Mailing Address
First Line	:	PO BOX 19305
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28219-9305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9908 COULOAK DR
Second Line	:	STE 201
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-8678
Country	:	US
Telephone Number	:	704-801-2075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	05/04/2023

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