Basic Information
Provider Information
NPI: 1447849575
EntityType: 2
ReplacementNPI:  
OrganizationName: KSJ MEDICAL LLC
LastName:  
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Mailing Information
Address1: 23 TODDINGTON TER
Address2:  
City: SAINT LOUIS
State: MO
PostalCode: 631282632
CountryCode: US
TelephoneNumber: 2014073489
FaxNumber:  
Practice Location
Address1: 10010 KENNERLY RD
Address2:  
City: SAINT LOUIS
State: MO
PostalCode: 631282106
CountryCode: US
TelephoneNumber: 3145251000
FaxNumber: 6363334510
Other Information
ProviderEnumerationDate: 01/13/2021
LastUpdateDate: 03/15/2021
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: JUMEAN
AuthorizedOfficialFirstName: KHALED
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 2014073489
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate: 03/15/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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