Provider Demographics
NPI:1063461416
Name:ROUSH, GLENN S (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:S
Last Name:ROUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 GREYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-1537
Mailing Address - Country:US
Mailing Address - Phone:937-393-6959
Mailing Address - Fax:937-393-6959
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5888
Practice Address - Country:US
Practice Address - Phone:505-332-6921
Practice Address - Fax:256-382-6455
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79-832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E47459Medicare UPIN