Healthcare Provider Details

I. General information

NPI: 1811156458
Provider Name (Legal Business Name): THOMAS G ROUSSEAU MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 COUNTRY CLUB DR
MARION KY
42064-1873
US

IV. Provider business mailing address

PO BOX 9150
PADUCAH KY
42002-9150
US

V. Phone/Fax

Practice location:
  • Phone: 270-744-9600
  • Fax: 270-744-0834
Mailing address:
  • Phone: 270-744-9600
  • Fax: 270-744-0834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number21441
License Number StateKY

VIII. Authorized Official

Name: LINDA DERR
Title or Position: PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 270-744-9600