Healthcare Provider Details

I. General information

NPI: 1528171964
Provider Name (Legal Business Name): THOMAS A ROISUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 S 5TH ST
ENID OK
73701-5832
US

IV. Provider business mailing address

261 HUMMINGBIRD LN
HANNIBAL MO
63401-6931
US

V. Phone/Fax

Practice location:
  • Phone: 913-396-8509
  • Fax: 913-318-8378
Mailing address:
  • Phone: 573-231-0130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number36424
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number15065
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number34698
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number109630
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD479037
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: