Basic Information
| Provider Information | |||||||||
| NPI: | 1578509345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROUSE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6640 INTECH BLVD | ||||||||
| Address2: | STE 195 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462782011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172950608 | ||||||||
| FaxNumber: | 3172950622 | ||||||||
| Practice Location | |||||||||
| Address1: | 6640 INTECH BLVD | ||||||||
| Address2: | SUITE 195 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462782011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172950608 | ||||||||
| FaxNumber: | 3172950622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 01040728 | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100357530 | 05 | IN | MEDICAID |