Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | DN007371 | GA |
Y | 213EG0000X | General Practice | DN007371 | GA |
NPI | 1003864935 |
---|---|
Provider Name | Dr. John A. Roush |
First Address | Fort Stewart, GA 31314-4703 |
Second Address | Fort Stewart, GA 31314-4703 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2006 |
Last Update Date | 08/07/2007 |