1265539050 NPI number — DR. CHRISTIE O MOUSAW DO

Table of content: DR. CHRISTIE O MOUSAW DO (NPI 1265539050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265539050 NPI number — DR. CHRISTIE O MOUSAW DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOUSAW
Provider First Name:
CHRISTIE
Provider Middle Name:
O
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'NEILL
Provider Other First Name:
CHRISTIE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265539050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 EVERGREEN DR
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
GLEN MILLS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19342-1059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-579-3555
Provider Business Mailing Address Fax Number:
610-579-3566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 EVERGREEN DR
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
GLEN MILLS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19342-1059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-579-3564
Provider Business Practice Location Address Fax Number:
610-579-3566
Provider Enumeration Date:
09/20/2006

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: 207Q00000X , with the licence number:  OS 012760 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101720742 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com