=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336029032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NOUR IBRAHIM MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2025
-----------------------------------------------------
Last Update Date | 09/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 S GRAND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63104-1016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-257-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3681 LINDELL BLVD APT 513
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63108-3363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-224-4092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 2025015467
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------