Provider Demographics
NPI:1164552741
Name:ROUSH, MARK ROBIN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBIN
Last Name:ROUSH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3779 DAYTON XENIA RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-2829
Mailing Address - Country:US
Mailing Address - Phone:937-426-3608
Mailing Address - Fax:
Practice Address - Street 1:3779 DAYTON XENIA RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2829
Practice Address - Country:US
Practice Address - Phone:937-426-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1004111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311132895-00OtherOHIO WORKERS COMP
OH000000012407OtherANTHEM
OH000000012407OtherANTHEM
OHRO 0566661Medicare ID - Type Unspecified