=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033116165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROULA AL-DAHHAK M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2005
-----------------------------------------------------
Last Update Date | 09/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 SAINT ELIZABETH BLVD STE 5000
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-1282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-641-5803
-----------------------------------------------------
Fax | 618-607-5116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 SAINT ELIZABETH BLVD STE 5000
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-1282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-641-5803
-----------------------------------------------------
Fax | 618-607-5116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 036176244
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | 35082826
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 35082826
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 2010011111
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------