Healthcare Provider Details

I. General information

NPI: 1497749089
Provider Name (Legal Business Name): NICHOLAS PANAGIOTIS ROUSSIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 RICHMOND AVE STE E
STATEN ISLAND NY
10314-1582
US

IV. Provider business mailing address

1655 RICHMOND AVE STE E
STATEN ISLAND NY
10314-1582
US

V. Phone/Fax

Practice location:
  • Phone: 718-682-1900
  • Fax: 718-682-1893
Mailing address:
  • Phone: 718-682-1900
  • Fax: 718-682-1893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number231555
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: