Healthcare Provider Details

I. General information

NPI: 1073778205
Provider Name (Legal Business Name): HABIB ELGHOUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 MARION AVE
MCCOMB MS
39648-2706
US

IV. Provider business mailing address

393 E WALNUT ST PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 601-249-1570
  • Fax: 601-249-1544
Mailing address:
  • Phone: 877-608-0044
  • Fax: 877-514-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberC133147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: