1417349234 NPI number — ROUBA GHOUSSOUB MD LLC

Table of content: (NPI 1417349234)

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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