Healthcare Provider Details

I. General information

NPI: 1124549993
Provider Name (Legal Business Name): TAHA MOUSSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number125.070604
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License NumberW0965
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: