Healthcare Provider Details

I. General information

NPI: 1831190834
Provider Name (Legal Business Name): AMAL RUSTOM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7691 POPLAR AVE
GERMANTOWN TN
38138-3904
US

IV. Provider business mailing address

8010 STAGE HILLS BLVD
BARTLETT TN
38133-4032
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-6970
  • Fax:
Mailing address:
  • Phone: 901-291-2400
  • Fax: 901-379-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number27218
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: