Provider Demographics
NPI:1720173438
Name:MAALOUF, BASSAM N (MD)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:N
Last Name:MAALOUF
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 1:210 W MCKINLEY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-5858
Mailing Address - Country:US
Mailing Address - Phone:217-329-3232
Mailing Address - Fax:217-342-2074
Practice Address - Street 1:321 REGENCY PARK STE 100
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1887
Practice Address - Country:US
Practice Address - Phone:618-416-7970
Practice Address - Fax:618-416-7971
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036133141207RH0003X, 207R00000X, 207RH0003X
KS0432016207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036133141Medicaid
IL036133141Medicaid
KS200429210CMedicaid