Provider Demographics
NPI:1578509345
Name:ROUSE, MARY D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:D
Last Name:ROUSE
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Gender:F
Credentials:MD
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Mailing Address - Street 1:6640 INTECH BLVD
Mailing Address - Street 2:STE 195
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-2011
Mailing Address - Country:US
Mailing Address - Phone:317-295-0608
Mailing Address - Fax:317-295-0622
Practice Address - Street 1:6640 INTECH BLVD
Practice Address - Street 2:SUITE 195
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-2011
Practice Address - Country:US
Practice Address - Phone:317-295-0608
Practice Address - Fax:317-295-0622
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-12-01
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Provider Licenses
StateLicense IDTaxonomies
IN010407282080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100357530Medicaid
INE52427Medicare UPIN
IN100357530Medicaid