Basic Information
| Provider Information | |||||||||
| NPI: | 1104842327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOURI-MOGHADDAM | ||||||||
| FirstName: | SORAYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | C B 8116 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144546095 | ||||||||
| FaxNumber: | 3144544801 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | SUITE 5S30 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144546095 | ||||||||
| FaxNumber: | 3144544801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 07/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | R8238 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 9170765004 | 05 | IL | MEDICAID | 200889129 | 05 | MO | MEDICAID |