Provider Demographics
NPI:1780610444
Name:CISSE, SALOUM (MD)
Entity type:Individual
Prefix:DR
First Name:SALOUM
Middle Name:
Last Name:CISSE
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:PO BOX 321359
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-1359
Mailing Address - Country:US
Mailing Address - Phone:601-936-1395
Mailing Address - Fax:601-526-0795
Practice Address - Street 1:119 S OAK
Practice Address - Street 2:SUITE 2
Practice Address - City:RAYMOND
Practice Address - State:MS
Practice Address - Zip Code:39154-4205
Practice Address - Country:US
Practice Address - Phone:601-526-0790
Practice Address - Fax:601-526-0795
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18216208M00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04036718Medicaid
MS04036718Medicaid