Provider Demographics
NPI:1568422673
Name:SOUKIEH, HOUSAM (MD)
Entity Type:Individual
Prefix:
First Name:HOUSAM
Middle Name:
Last Name:SOUKIEH
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 1:1513 UNION AVE
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-9402
Mailing Address - Country:US
Mailing Address - Phone:660-263-2400
Mailing Address - Fax:660-263-5610
Practice Address - Street 1:1513 UNION AVE
Practice Address - Street 2:SUITE 1600
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-9402
Practice Address - Country:US
Practice Address - Phone:660-263-2400
Practice Address - Fax:660-263-5610
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101288207RP1001X
MO2014021757207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101288Medicaid
ILL73045Medicare ID - Type Unspecified
ILE93838Medicare UPIN