Provider Demographics
NPI:1710914247
Name:ROUSE, CHARLIE C (MD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:C
Last Name:ROUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 BANKHEAD HWY
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3425
Mailing Address - Country:US
Mailing Address - Phone:770-838-8440
Mailing Address - Fax:770-838-8443
Practice Address - Street 1:129 BANKHEAD HWY
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3425
Practice Address - Country:US
Practice Address - Phone:770-838-8440
Practice Address - Fax:770-838-8443
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044076207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00857Medicare UPIN