Healthcare Provider Details

I. General information

NPI: 1881009256
Provider Name (Legal Business Name): HUSSEIN EBRO WALIYE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10012 KENNERLY RD STE 406
SAINT LOUIS MO
63128-2197
US

IV. Provider business mailing address

10012 KENNERLY RD STE 406
SAINT LOUIS MO
63128-2197
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1224
  • Fax:
Mailing address:
  • Phone: 314-525-1224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301106134
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2019024497
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: