NPIMap

Organization Active NPI

DRS. Roush & Will Optometrists Inc

  • Optometrist
  • Kendallville, IN
National Provider Identifier
1578613295
Registry record updated Jul 22, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
DRS. ROUSH & WILL OPTOMETRISTS INC
Practice address
781 E. North St
Kendallville, IN 46755-1225
Phone
(260) 347-3611
Fax
(260) 347-4425
NPI assigned
Jan 12, 2007
Last updated
Jul 22, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 22, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. R Alan Roush, O.D.
Title
President
Phone
(260) 347-3611

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Eyewear Supplier 332H00000X 0921390001 IN
Optometrist 152W00000X Primary

Addresses

Primary practice location

781 E. North St
Kendallville, IN 46755-1225

Mailing address

781 E. North St
Kendallville, IN 46755-1225
Phone (260) 347-3611

Other identifiers 3

IdentifierTypeStateIssuer
100355140AMedicaidIN
100355140CMedicaidIN
100355140BMedicaidIN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040908001624 IN Part B Supplier - Clinic/Group Practice 9830165026 Receives reassigned benefits from 5 practitioners
Practice locations: Albion, IN; Kendallville, IN; Ligonier, IN

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
DRS Roush Will Optometrists2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

815 Trail Ridge Rd
Albion, IN 46701
Phone (260) 636-7788

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168560000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1469145600000",
    "number": "1578613295",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "781 E. NORTH ST",
            "city": "KENDALLVILLE",
            "state": "IN",
            "postal_code": "467551225",
            "telephone_number": "260-347-3611",
            "fax_number": "260-347-4425"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "781 E. NORTH ST",
            "city": "KENDALLVILLE",
            "state": "IN",
            "postal_code": "467551225",
            "telephone_number": "260-347-3611",
            "fax_number": "260-347-4425"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DRS. ROUSH & WILL OPTOMETRISTS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-12",
        "last_updated": "2016-07-22",
        "status": "A",
        "authorized_official_last_name": "ROUSH",
        "authorized_official_first_name": "R ALAN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "260-347-3611",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "IN",
            "license": "0921390001",
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100355140A",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100355140C",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100355140B",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kendallville, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.