Provider Demographics
NPI:1447849575
Name:KSJ MEDICAL LLC
Entity type:Organization
Organization Name:KSJ MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:
Authorized Official - Last Name:JUMEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-407-3489
Mailing Address - Street 1:23 TODDINGTON TER
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2632
Mailing Address - Country:US
Mailing Address - Phone:201-407-3489
Mailing Address - Fax:
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-1000
Practice Address - Fax:636-333-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-13
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty