MEDICARE: DR. BASSAM A. ROUKOZ 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	207RC0000X	Cardiovascular Disease Physician	2003007582	MO
2	207RI0011X	Interventional Cardiology Physician	190958	MO

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396744439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BASSAM A. ROUKOZ M.D.

Provider Business Mailing Address
First Line	:	12855 N FORTY DR
Second Line	:	SUITE 300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8666
Country	:	US
Telephone Number	:	314-880-6100
Fax Number	:	314-997-3248

Provider Business Practice Location Address
First Line	:	1390 HIGHWAY 61
Second Line	:	SUITE 3300
City	:	FESTUS
State	:	MO
Zip	:	63028-4137
Country	:	US
Telephone Number	:	636-931-6302
Fax Number	:	636-931-3609

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

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	06/26/2012

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Directions to “ DR. BASSAM A. ROUKOZ M.D.” Practice Location

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