Provider Demographics
NPI:1518543065
Name:EL KOUSSA, ROY
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:EL KOUSSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 HOMESTRETCH DR
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-5392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MERCYHEALTH MULFORD
Practice Address - Street 2:5970 CHURCHVIEW DRIVE
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2574
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.168094207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program