Basic Information
| Provider Information | |||||||||
| NPI: | 1184680993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUSE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4907 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008312402 | ||||||||
| FaxNumber: | 7706669514 | ||||||||
| Practice Location | |||||||||
| Address1: | 4955 F STREET | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027172870 | ||||||||
| FaxNumber: | 4027175231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 06/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 17631 | NE | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZC0500X | 28682 | IA | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | 17631 | NE | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 28682 | IA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 47016 | 01 | IA | BCBS | OTHER | 06294 | 01 | NE | BCBS | OTHER |