Basic Information
| Provider Information | |||||||||
| NPI: | 1871540088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALLOUM | ||||||||
| FirstName: | ELLIS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SALLOUM | ||||||||
| OtherFirstName: | ELLIS | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1225 CAMPBELL WAY STE 101 | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604794203 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 CAMPBELL WAY STE 101 | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604794203 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | MD60941287 | WA | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 36455 | AL | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | MD60941287 | WA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2147693 | 05 | WA | MEDICAID |