Healthcare Provider Details

I. General information

NPI: 1417349234
Provider Name (Legal Business Name): ROUBA GHOUSSOUB MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61 G30
FESTUS MO
63028-4100
US

IV. Provider business mailing address

PO BOX 1449
MARYLAND HEIGHTS MO
63043-0449
US

V. Phone/Fax

Practice location:
  • Phone: 636-931-7770
  • Fax: 636-931-7671
Mailing address:
  • Phone: 314-432-2580
  • Fax: 314-432-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROUBA GHOUSSOUB
Title or Position: OWNER
Credential: M.D.
Phone: 636-931-7770