Basic Information
| Provider Information | |||||||||
| NPI: | 1720173438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAALOUF | ||||||||
| FirstName: | BASSAM | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 W MCKINLEY AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625265858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173293232 | ||||||||
| FaxNumber: | 2173422074 | ||||||||
| Practice Location | |||||||||
| Address1: | 321 REGENCY PARK STE 100 | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622691887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184167970 | ||||||||
| FaxNumber: | 6184167971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036133141 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 036133141 | 05 | IL | MEDICAID |