Healthcare Provider Details

I. General information

NPI: 1336029032
Provider Name (Legal Business Name): NOUR IBRAHIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

3681 LINDELL BLVD APT 513
SAINT LOUIS MO
63108-3363
US

V. Phone/Fax

Practice location:
  • Phone: 314-257-8000
  • Fax:
Mailing address:
  • Phone: 314-224-4092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number2025015467
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: