Provider Demographics
NPI:1871777102
Name:ROUSOU, ANTHONY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOHN
Last Name:ROUSOU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:ROUSOU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:280 CHESTNUT ST FL 2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL CENTER DR STE 512
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1273
Practice Address - Country:US
Practice Address - Phone:413-794-5550
Practice Address - Fax:413-794-4212
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213069208G00000X
CT390200000X208G00000X
WI55213-20208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123501Medicaid
WI1871777102Medicaid
IN201019550BMedicaid
IL01618941OtherBC/BS
ILP00791177Medicare PIN
WIWI2609003Medicare PIN
WI1871777102Medicaid
IL535550001Medicare PIN
IL969780001Medicare PIN