Healthcare Provider Details

I. General information

NPI: 1023013307
Provider Name (Legal Business Name): PERICLIS ROUSSIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 19TH ST. SUITE 401
KNOXVILLE TN
37916-1839
US

IV. Provider business mailing address

501 19TH ST. SUITE 401
KNOXVILLE TN
37916-1839
US

V. Phone/Fax

Practice location:
  • Phone: 865-331-2020
  • Fax: 865-331-2019
Mailing address:
  • Phone: 865-331-2020
  • Fax: 865-331-2019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberMD18681
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: