Provider Demographics
NPI:1558374124
Name:ROUSE, KEITH A (DPM)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:ROUSE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 EISENHOWER DR
Mailing Address - Street 2:BLDG 7A
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2632
Mailing Address - Country:US
Mailing Address - Phone:912-355-6503
Mailing Address - Fax:912-355-9837
Practice Address - Street 1:310 EISENHOWER DR
Practice Address - Street 2:BLDG 7
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2632
Practice Address - Country:US
Practice Address - Phone:912-355-6503
Practice Address - Fax:912-355-9837
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA885213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000880514AMedicaid
GA0634000002Medicare NSC
GA000880514AMedicaid
GA48SCCFH02Medicare PIN