Provider Demographics
NPI:1275665523
Name:ROUSE FAMILY MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:ROUSE FAMILY MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO ROUSE FAMILY MEDICAL CLINIC PA
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-443-0500
Mailing Address - Street 1:1306 S PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6223
Mailing Address - Country:US
Mailing Address - Phone:479-443-0500
Mailing Address - Fax:479-521-3832
Practice Address - Street 1:1306 S PLEASANT ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6223
Practice Address - Country:US
Practice Address - Phone:479-443-0500
Practice Address - Fax:479-521-3832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR012083557OtherUHC
AR126089002OtherMEDICAID GROUP
AR122530000OtherQUALCHOICE QC
AR106345001Medicaid
D04889Medicare UPIN
AR122530000OtherQUALCHOICE QC