Healthcare Provider Details

I. General information

NPI: 1548656747
Provider Name (Legal Business Name): MAAROOF ISLAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT ELIZABETH BLVD
O FALLON IL
62269
US

IV. Provider business mailing address

7900 LEES SUMMIT RD
KANSAS CITY MO
64139-1236
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-2120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036146913
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2015017276
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036146913
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036146913
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: