Provider Demographics
NPI:1205025624
Name:JOHN L. ROUSSALIS M.D., P.C.
Entity Type:Organization
Organization Name:JOHN L. ROUSSALIS M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:ROUSSALIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-234-4585
Mailing Address - Street 1:1129 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2903
Mailing Address - Country:US
Mailing Address - Phone:307-234-4585
Mailing Address - Fax:307-265-7479
Practice Address - Street 1:1129 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2903
Practice Address - Country:US
Practice Address - Phone:307-234-4585
Practice Address - Fax:307-265-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7691A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY21591Medicare PIN