Provider Demographics
NPI:1851421705
Name:AL-GEBORY, FARIS (MD)
Entity Type:Individual
Prefix:
First Name:FARIS
Middle Name:
Last Name:AL-GEBORY
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 1:12236 WINROCK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6642
Mailing Address - Country:US
Mailing Address - Phone:314-432-5144
Mailing Address - Fax:
Practice Address - Street 1:763 S NEW BALLAS RD
Practice Address - Street 2:SUITE 350
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8704
Practice Address - Country:US
Practice Address - Phone:314-432-5144
Practice Address - Fax:314-432-2400
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036131427208600000X
MO2008032789207P00000X
RIMD11328208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1851421705Medicaid
RIFA0077568OtherDEA
NYA300000256Medicare PIN
NYG300000049Medicare PIN
MO1851421705Medicaid