1770591190 NPI number — DR. DWIGHT J ROUSE MD, MSPH

Table of content: DR. DWIGHT J ROUSE MD, MSPH (NPI 1770591190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770591190 NPI number — DR. DWIGHT J ROUSE MD, MSPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUSE
Provider First Name:
DWIGHT
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, MSPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770591190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 TOLL GATE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARWICK
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02886-2759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-274-1122
Provider Business Mailing Address Fax Number:
401-453-7622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 PLAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02903-4828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-274-1122
Provider Business Practice Location Address Fax Number:
401-453-7622
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VM0101X , with the licence number:  MD13078 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009970485 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009970495 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051521267 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000093716 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009952725 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051521268 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000084538 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000084538 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009936015 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009952745 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009970475 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051521269 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000093716 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051518077 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009952705 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051521270 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009952735 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051521271 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009952695 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009952715 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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