Basic Information
| Provider Information | |||||||||
| NPI: | 1265539050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOUSAW | ||||||||
| FirstName: | CHRISTIE | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O'NEILL | ||||||||
| OtherFirstName: | CHRISTIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 EVERGREEN DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | GLEN MILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193421059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105793555 | ||||||||
| FaxNumber: | 6105793566 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 EVERGREEN DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | GLEN MILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193421059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105793564 | ||||||||
| FaxNumber: | 6105793566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS 012760 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 101720742 | 05 | PA | MEDICAID |