Basic Information
| Provider Information | |||||||||
| NPI: | 1548471493 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MOUSSA | ||||||||
| FirstName: | MOHAMAD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4510 DORR ST # MS 840 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436154040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835334 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193836310 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PH0002X | 4301084214 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine | 207P00000X | 35.092517 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000595930 | 01 | OH | ANTHEM BCBS | OTHER | 2943588 | 05 | OH | MEDICAID |