Provider Demographics
NPI:1417349234
Name:ROUBA GHOUSSOUB MD LLC
Entity Type:Organization
Organization Name:ROUBA GHOUSSOUB MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROUBA
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOUSSOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-931-7770
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0449
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-432-0223
Practice Address - Street 1:1400 US HIGHWAY 61
Practice Address - Street 2:G30
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4100
Practice Address - Country:US
Practice Address - Phone:636-931-7770
Practice Address - Fax:636-931-7671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1417349234Medicaid
MO1417349234Medicaid
MOMA5469Medicare PIN