Basic Information
| Provider Information | |||||||||
| NPI: | 1083697122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALEH | ||||||||
| FirstName: | MAHMOUD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6800 STATE ROUTE 162 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 108467 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 108467 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036093369 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | 036093369 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204666838 | 05 | MO | MEDICAID | 204666804 | 05 | MO | MEDICAID | 204666846 | 05 | MO | MEDICAID | 204666812 | 05 | MO | MEDICAID |