Basic Information
| Provider Information | |||||||||
| NPI: | 1184677262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSSEIN | ||||||||
| FirstName: | MOHAMED | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2316 W 23RD ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324052373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505224770 | ||||||||
| FaxNumber: | 8505224760 | ||||||||
| Practice Location | |||||||||
| Address1: | 2316 W 23RD ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324052373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505224770 | ||||||||
| FaxNumber: | 8505224760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 08/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT8384 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 202945722 | 01 | FL | TRICARE | OTHER | Q6A | 01 | FL | BCBS OF FL | OTHER | 5668714 | 01 | FL | AETNA | OTHER | 891217300 | 05 | FL | MEDICAID |