Provider Demographics
NPI:1598876617
Name:SALLAH, MOMODOU (PA-C)
Entity Type:Individual
Prefix:
First Name:MOMODOU
Middle Name:
Last Name:SALLAH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 DANIELLE CT
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1545
Mailing Address - Country:US
Mailing Address - Phone:618-997-5311
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85001515363AM0700X
IL085001515207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1682031Medicare PIN
P93195Medicare UPIN
ILK49121Medicare PIN