Healthcare Provider Details

I. General information

NPI: 1750483848
Provider Name (Legal Business Name): CARDIOVASCULAR MEDICINE OF CLEVELAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21500 LORAIN RD
FAIRVIEW PARK OH
44126-3302
US

IV. Provider business mailing address

PO BOX 450615
WESTLAKE OH
44145-0611
US

V. Phone/Fax

Practice location:
  • Phone: 440-356-6666
  • Fax: 440-356-6651
Mailing address:
  • Phone: 440-356-6666
  • Fax: 440-356-6651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35-071087
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number35-071087
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number35-071087
License Number StateOH

VIII. Authorized Official

Name: DR. BASEL Z MOUSSA
Title or Position: OWNER
Credential: M.D.
Phone: 440-356-6666