Healthcare Provider Details

I. General information

NPI: 1629207477
Provider Name (Legal Business Name): ELSAYED SALEM ABO-SALEM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11125 DUNN RD STE 204
SAINT LOUIS MO
63136-6188
US

IV. Provider business mailing address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

V. Phone/Fax

Practice location:
  • Phone: 314-839-5522
  • Fax:
Mailing address:
  • Phone: 314-268-7992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number35129185
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036143069
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number2016023781
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: