Basic Information
| Provider Information | |||||||||
| NPI: | 1558563890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELSIDDIG | ||||||||
| FirstName: | HASSAN | ||||||||
| MiddleName: | DAWOUD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1083 RUE LA VILLE WALK | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145422501 | ||||||||
| FaxNumber: | 3147718575 | ||||||||
| Practice Location | |||||||||
| Address1: | 3660 VISTA AVE # 204 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149778462 | ||||||||
| FaxNumber: | 3147718575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 2005027548 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.