Provider Demographics
NPI:1891799847
Name:ROUSE WONG, ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ROUSE WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:FRANCES
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-968-6226
Mailing Address - Fax:502-966-5567
Practice Address - Street 1:5100 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-4056
Practice Address - Country:US
Practice Address - Phone:502-968-6226
Practice Address - Fax:502-966-5567
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64274350Medicaid
KY076693OtherSIHO/NORTON
KYP00386070OtherRAILROAD MEDICARE KY/NORT
000000479493OtherANTHEM - NCMA
KY283734000OtherPASSPORT ADVANTAGE/NORTON
KY50014617OtherPASSPORT/NORTON
KY50014617OtherPASSPORT/NORTON
KYK179480Medicare PIN
KY076693OtherSIHO/NORTON