Healthcare Provider Details

I. General information

NPI: 1568456382
Provider Name (Legal Business Name): GEORGE PANAGIOTIS ROUSSIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627B HYLAN BLVD
STATEN ISLAND NY
10306-4353
US

IV. Provider business mailing address

2627B HYLAN BLVD
STATEN ISLAND NY
10306-4353
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-5500
  • Fax: 718-667-5510
Mailing address:
  • Phone: 718-667-5500
  • Fax: 718-667-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number224106
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: