Provider Demographics
NPI:1396744439
Name:ROUKOZ, BASSAM A (MD)
Entity type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:A
Last Name:ROUKOZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:12855 N FORTY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8666
Mailing Address - Country:US
Mailing Address - Phone:314-880-6100
Mailing Address - Fax:314-997-3248
Practice Address - Street 1:1390 HIGHWAY 61
Practice Address - Street 2:SUITE 3300
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4137
Practice Address - Country:US
Practice Address - Phone:636-931-6302
Practice Address - Fax:636-931-3609
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2012-06-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2003007582207RC0000X
MO190958207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208766204Medicaid
MO208766212Medicaid
MOH83389Medicare UPIN
MO208766204Medicaid
MO208766212Medicaid
P00021879Medicare PIN