Healthcare Provider Details

I. General information

NPI: 1053345231
Provider Name (Legal Business Name): BASSAM AR HADI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10012 KENNERLY RD STE 400
SAINT LOUIS MO
63128-2197
US

IV. Provider business mailing address

10012 KENNERLY RD STE 400
SAINT LOUIS MO
63128-2197
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5999
  • Fax:
Mailing address:
  • Phone: 314-543-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2003009742
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: