Provider Demographics
NPI:1255357091
Name:ROUSH, RANDALL D (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:D
Last Name:ROUSH
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 1:1805 SUMMER BLOSSOM PL
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12266 DEPAUL DR
Practice Address - Street 2:110
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2514
Practice Address - Country:US
Practice Address - Phone:314-291-7900
Practice Address - Fax:314-291-7914
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9C72207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207746603Medicaid
MOA13445Medicare UPIN
MO007010855Medicare ID - Type Unspecified