Provider Demographics
NPI:1629018320
Name:ROUSH ICENHOWER, KELLY J (DC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:ROUSH ICENHOWER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5244
Mailing Address - Fax:740-446-5565
Practice Address - Street 1:1051 4TH AVE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1612
Practice Address - Country:US
Practice Address - Phone:740-446-5244
Practice Address - Fax:740-446-5565
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2510111N00000X
OH2510111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
350039394OtherRR MEDICARE
OH000000185276OtherUNISON MEDICAID
OH2026677Medicaid
000000007692OtherANTHEM BCBS
WV0132242000Medicaid
001714092OtherMOUNTAIN STATE BCBS
OH310917085149OtherCARESOURCE MEDICAID
WV0132242000Medicaid
350039394OtherRR MEDICARE