Provider Demographics
NPI:1194910166
Name:LISA ROUSE, M.D., P.A.
Entity type:Organization
Organization Name:LISA ROUSE, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-896-0404
Mailing Address - Street 1:707 HILL COUNTRY DR STE 106
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5910
Mailing Address - Country:US
Mailing Address - Phone:830-896-0404
Mailing Address - Fax:830-896-4343
Practice Address - Street 1:707 HILL COUNTRY DR STE 106
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5910
Practice Address - Country:US
Practice Address - Phone:830-896-0404
Practice Address - Fax:830-896-4343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00693RMedicare PIN