Basic Information
| Provider Information | |||||||||
| NPI: | 1568551042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONEM | ||||||||
| FirstName: | GAMAL | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 STANLEY GAULT PARKWAY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022382801 | ||||||||
| FaxNumber: | 5022382835 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 KRESGE WAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028978100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 06/29/2009 | ||||||||
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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 | 208000000X | 31840 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | 31840 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31840 | 01 | KY | KY MD LICENSE | OTHER | BA2928084 | 01 | KY | DEA# | OTHER | 6431840500 | 05 | KY | MEDICAID | 50014082 | 01 | KY | PASSPORT | OTHER |