Basic Information
| Provider Information | |||||||||
| NPI: | 1740288356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUKIS | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | SEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1836 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546015429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087827300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 016-004963 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | PO00000811 | WA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | PO4225 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 779 | WI | N | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 016004963 | 05 | IL | MEDICAID | 60000380 | 01 | IL | BCBS | OTHER |