Provider Demographics
NPI:1194949784
Name:BISHARA, SAM G (MD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:G
Last Name:BISHARA
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Gender:M
Credentials:MD
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Mailing Address - Street 1:11125 DUNN RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6132
Mailing Address - Country:US
Mailing Address - Phone:314-839-5522
Mailing Address - Fax:314-839-5351
Practice Address - Street 1:11125 DUNN RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-839-5522
Practice Address - Fax:314-839-5351
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2020-11-12
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Provider Licenses
StateLicense IDTaxonomies
MO2009031839207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO$$$$$$$$$Medicaid
IL707950002Medicare UPIN
MO$$$$$$$$$Medicaid