Healthcare Provider Details

I. General information

NPI: 1790992675
Provider Name (Legal Business Name): FADEE ABU AL RUB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTER FOR SPECIALIZED MEDICINE 1225 S GRAND BLVD.
ST. LOUIS MO
63104
US

IV. Provider business mailing address

CENTER FOR SPECIALIZED MEDICINE 1225 S GRAND BLVD.
ST. LOUIS MO
63104
US

V. Phone/Fax

Practice location:
  • Phone: 314-257-3760
  • Fax:
Mailing address:
  • Phone: 314-257-3760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036139742
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2013042711
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2013042711
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: