Healthcare Provider Details

I. General information

NPI: 1922499508
Provider Name (Legal Business Name): ELIE MOUSSALLEM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR STE B260
GREENVILLE SC
29615-6328
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-2852
  • Fax: 864-454-2899
Mailing address:
  • Phone: 864-522-8617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number81527
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number81527
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: