Basic Information
| Provider Information | |||||||||
| NPI: | 1023207115 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ELAYYAN | ||||||||
| FirstName: | IBRAHIM | ||||||||
| MiddleName: | B.I. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12101 WOODCREST EXECUTIVE DR | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631415047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SAINT ANTHONYS WAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620024568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2007 | ||||||||
| LastUpdateDate: | 04/22/2014 | ||||||||
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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 | 207R00000X | 036.125535 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 036.125535 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1023207115 | 05 | IL | MEDICAID |