Healthcare Provider Details

I. General information

NPI: 1003462771
Provider Name (Legal Business Name): WASSIM MOURAD MD, MHCM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2019
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 S SPRING AVE RM 1114
SAINT LOUIS MO
63110-2520
US

IV. Provider business mailing address

1008 S SPRING AVE RM 1114
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4102
  • Fax:
Mailing address:
  • Phone: 314-977-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4351044074
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number2022040004
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: