Healthcare Provider Details

I. General information

NPI: 1891427472
Provider Name (Legal Business Name): MAHMOUD BALLOUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W 10TH ST
ROLLA MO
65401-2905
US

IV. Provider business mailing address

1050 W 10TH ST
ROLLA MO
65401-2905
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-9000
  • Fax: 573-426-2108
Mailing address:
  • Phone: 573-364-9000
  • Fax: 573-426-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2025026526
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2025026526
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: