Healthcare Provider Details

I. General information

NPI: 1154656882
Provider Name (Legal Business Name): TAREK MOUSSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4437 STATE ROUTE 159 STE 125
CHILLICOTHEE OH
45601-7065
US

IV. Provider business mailing address

4437 STATE ROUTE 159 STE 125
CHILLICOTHEE OH
45601-7065
US

V. Phone/Fax

Practice location:
  • Phone: 740-779-4570
  • Fax: 740-779-4579
Mailing address:
  • Phone: 740-374-4500
  • Fax: 740-374-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35095949
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number35.095949
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: