Basic Information
| Provider Information | |||||||||
| NPI: | 1619233723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHOSSEIN | ||||||||
| FirstName: | MAROUN | ||||||||
| MiddleName: | MAURICE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022725754 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 W MARKET ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025878000 | ||||||||
| FaxNumber: | 5025838001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2012 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 57.021073 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 52259 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 208000000X | 57.021073 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 207RP1001X | 52259 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 7100628490 | 05 | KY | MEDICAID | 300031621 | 05 | IN | MEDICAID |