Provider Demographics
NPI:1528581683
Name:GHOSSOUB, ELIAS (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:
Last Name:GHOSSOUB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1438 S GRAND BLVD RM 7
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1027
Mailing Address - Country:US
Mailing Address - Phone:314-977-4826
Mailing Address - Fax:314-977-1099
Practice Address - Street 1:1438 S GRAND BLVD RM 7
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1027
Practice Address - Country:US
Practice Address - Phone:314-977-4826
Practice Address - Fax:314-977-1099
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170188632084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry