1902827603 NPI number — GEORGE THOMAS SALLOUM M.D.

Table of content: DENISE BUTLER-OWEN LCSW (NPI 1174653265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902827603 NPI number — GEORGE THOMAS SALLOUM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALLOUM
Provider First Name:
GEORGE
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1902827603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6300 E LAKE BLVD
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
VANCLEAVE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39565-6770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-230-2663
Provider Business Mailing Address Fax Number:
228-206-1192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720A MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39532-2129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-392-9355
Provider Business Practice Location Address Fax Number:
228-392-1781
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  15531 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00124267 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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