Healthcare Provider Details

I. General information

NPI: 1407891708
Provider Name (Legal Business Name): SAMIR MOUSSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7206 MARKET ST SUITE A
YOUNGSTOWN OH
44512-4507
US

IV. Provider business mailing address

PO BOX 1239
TROY MI
48099-1239
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-3379
  • Fax: 330-726-8683
Mailing address:
  • Phone: 248-824-6622
  • Fax: 248-324-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD039456L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35054126
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: