1467563429 NPI number — BASEL MOUSSA MD

Table of content: BASEL MOUSSA MD (NPI 1467563429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467563429 NPI number — BASEL MOUSSA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOUSSA
Provider First Name:
BASEL
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:
1467563429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/17/2007
NPI Reactivation Date:
09/07/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 450615
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST LAKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-356-6666
Provider Business Mailing Address Fax Number:
440-356-6651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20997 LORAIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRVIEW PARK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-356-6666
Provider Business Practice Location Address Fax Number:
440-356-6651
Provider Enumeration Date:
08/31/2006

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: 174400000X , with the licence number:  35-071087 , 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: 000000152232 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 522125821 . This is a "PROVIDER NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0852635 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 522125821026 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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