Provider Demographics
NPI:1871540088
Name:SALLOUM, ELLIS J (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:J
Last Name:SALLOUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ELLIS
Other - Middle Name:J
Other - Last Name:SALLOUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1225 CAMPBELL WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3323
Mailing Address - Country:US
Mailing Address - Phone:360-479-4203
Mailing Address - Fax:253-426-6344
Practice Address - Street 1:1225 CAMPBELL WAY STE 101
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3323
Practice Address - Country:US
Practice Address - Phone:360-479-4203
Practice Address - Fax:253-426-6344
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD609412872086S0129X, 208600000X
AL364552086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2147693Medicaid
LAH55298Medicare UPIN