Basic Information
| Provider Information | |||||||||
| NPI: | 1467460055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROUSE | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5435 FELTL ROAD | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553437983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528359880 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5435 FELTL RD | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553437983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528359880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 207Q00000X | 35813 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 35813 | MN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 716870500 | 05 | MN | MEDICAID |