Provider Demographics
NPI:1245233725
Name:NEW SMYRNA BEACH GYNECOLOGY & OBSTETRICS PA
Entity Type:Organization
Organization Name:NEW SMYRNA BEACH GYNECOLOGY & OBSTETRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:DUDLEY
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:386-423-0333
Mailing Address - Street 1:603 S ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7320
Mailing Address - Country:US
Mailing Address - Phone:386-423-0333
Mailing Address - Fax:386-423-0042
Practice Address - Street 1:603 S ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7320
Practice Address - Country:US
Practice Address - Phone:386-423-0333
Practice Address - Fax:386-423-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32999207V00000X
FLRN2893652363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCK2855Medicare PIN
FLK3179Medicare PIN