Healthcare Provider Details

I. General information

NPI: 1053845321
Provider Name (Legal Business Name): ABDULLAH AL MASUD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 SOUTH SPRING GIM, 2ND FLOOR
ST. LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-257-8222
  • Fax: 314-577-8019
Mailing address:
  • Phone: 314-257-8222
  • Fax: 314-577-8019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2020023585
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: