Healthcare Provider Details

I. General information

NPI: 1164497525
Provider Name (Legal Business Name): IBRAHIM A MOURAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19550 E 39TH ST S SUITE 400
INDEPENDENCE MO
64057-2303
US

IV. Provider business mailing address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

V. Phone/Fax

Practice location:
  • Phone: 816-254-4800
  • Fax: 816-254-4641
Mailing address:
  • Phone: 618-257-6220
  • Fax: 618-257-6679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2009021594
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036-147746
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: