Provider Demographics
NPI:1083697122
Name:SALEH, MAHMOUD A (MD)
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:A
Last Name:SALEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8500
Practice Address - Country:US
Practice Address - Phone:800-968-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108467207P00000X, 207R00000X
IL036093369207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204666838Medicaid
MO204666804Medicaid
MO204666846Medicaid
MO204666812Medicaid
MO204666838Medicaid
MO204666812Medicaid
IL$$$$$$$$$-9Medicaid
MO909953212Medicare PIN
ILG45777Medicare UPIN
G45777Medicare UPIN
ILK06518Medicare ID - Type Unspecified
MO204666804Medicaid
MO204666846Medicaid
MO009013213Medicare PIN
ILIL1682024Medicare PIN