1417349234 NPI number — ROUBA GHOUSSOUB MD LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417349234 NPI number — ROUBA GHOUSSOUB MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROUBA GHOUSSOUB MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417349234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1449
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYLAND HEIGHTS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63043-0449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-432-2580
Provider Business Mailing Address Fax Number:
314-432-0223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 US HIGHWAY 61
Provider Second Line Business Practice Location Address:
G30
Provider Business Practice Location Address City Name:
FESTUS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63028-4100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-931-7770
Provider Business Practice Location Address Fax Number:
636-931-7671
Provider Enumeration Date:
03/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GHOUSSOUB
Authorized Official First Name:
ROUBA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
636-931-7770

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1417349234 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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