Healthcare Provider Details

I. General information

NPI: 1174064596
Provider Name (Legal Business Name): OMAR HANI ELSAYED-ALI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 MID AMERICA PLZ DIV IM ALLERGY AND IMMUNOLOGY, STE 2300
SAINT LOUIS MO
63129-0002
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-8670
  • Fax: 866-362-4984
Mailing address:
  • Phone: 314-996-8670
  • Fax: 866-362-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019034401
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019034401
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2019034401
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number2019034401
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: