Provider Demographics
NPI:1912048703
Name:SROUR MALLAH, HUSAM (MD)
Entity type:Individual
Prefix:
First Name:HUSAM
Middle Name:
Last Name:SROUR MALLAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 W THUNDERBIRD RD STE W310
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4644
Mailing Address - Country:US
Mailing Address - Phone:602-865-4011
Mailing Address - Fax:602-865-4250
Practice Address - Street 1:5757 W THUNDERBIRD RD STE W310
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4644
Practice Address - Country:US
Practice Address - Phone:602-865-4011
Practice Address - Fax:602-865-4250
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067525A208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000664359OtherANTHEM
IN200987180Medicaid