MEDICARE: GERALD R ROUSSEAU PT

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	225100000X	Physical Therapist	1622	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	408399	OTHER		BLUECHIP

General Provider Information

NPI Number	:	1437124328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD R ROUSSEAU PT

Provider Business Mailing Address
First Line	:	300 TOWER HILL RD
Second Line	:	UNIT 128
City	:	NORTH KINGSTOWN
State	:	RI
Zip	:	02852-4814
Country	:	US
Telephone Number	:	401-295-8500
Fax Number	:	401-295-8536

Provider Business Practice Location Address
First Line	:	24 SALT POND RD
Second Line	:	H-5
City	:	WAKEFIELD
State	:	RI
Zip	:	02879-4314
Country	:	US
Telephone Number	:	401-792-8500
Fax Number	:	401-792-8877

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

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	04/05/2016

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