Provider Demographics
NPI:1689610230
Name:ROUSE, KELLY (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ROUSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 20TH ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1809
Mailing Address - Country:US
Mailing Address - Phone:865-541-1750
Mailing Address - Fax:865-541-1751
Practice Address - Street 1:501 20TH ST
Practice Address - Street 2:SUITE 503
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1809
Practice Address - Country:US
Practice Address - Phone:865-541-1750
Practice Address - Fax:865-541-1751
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1646207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3304318Medicaid
TN3304318Medicaid
I21080Medicare UPIN
TN3734041Medicare PIN
TN3304318Medicaid
TN3304318Medicare ID - Type UnspecifiedLEGACY PIN