1154656882 NPI number — TAREK MOUSSA MD

Table of content: TAREK MOUSSA MD (NPI 1154656882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154656882 NPI number — TAREK MOUSSA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOUSSA
Provider First Name:
TAREK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154656882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4437 STATE ROUTE 159
Provider Second Line Business Mailing Address:
STE 125
Provider Business Mailing Address City Name:
CHILLICOTHEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45601-7065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-374-4500
Provider Business Mailing Address Fax Number:
740-374-5887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4437 STATE ROUTE 159 STE 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHILLICOTHEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45601-7065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-779-4570
Provider Business Practice Location Address Fax Number:
740-779-4579
Provider Enumeration Date:
10/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  35095949 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 35.095949 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3101002 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810018548 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00931604 . This is a "RRMCR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000669833 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000696921 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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