Healthcare Provider Details

I. General information

NPI: 1528581683
Provider Name (Legal Business Name): ELIAS GHOSSOUB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 S GRAND BLVD RM 7
SAINT LOUIS MO
63104-1027
US

IV. Provider business mailing address

1438 S GRAND BLVD RM 7
SAINT LOUIS MO
63104-1027
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4826
  • Fax: 314-977-1099
Mailing address:
  • Phone: 314-977-4826
  • Fax: 314-977-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number2017018863
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: