MEDICARE: DR. PERICLIS ROUSSIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VM0101X	Maternal & Fetal Medicine Physician	MD18681	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4061072	OTHER	TN	BCBS

General Provider Information

NPI Number	:	1023013307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PERICLIS ROUSSIS M.D.

Provider Business Mailing Address
First Line	:	501 19TH ST.
Second Line	:	SUITE 401
City	:	KNOXVILLE
State	:	TN
Zip	:	37916-1839
Country	:	US
Telephone Number	:	865-331-2020
Fax Number	:	865-331-2019

Provider Business Practice Location Address
First Line	:	501 19TH ST.
Second Line	:	SUITE 401
City	:	KNOXVILLE
State	:	TN
Zip	:	37916-1839
Country	:	US
Telephone Number	:	865-331-2020
Fax Number	:	865-331-2019

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	04/26/2017

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