Healthcare Provider Details

I. General information

NPI: 1114998671
Provider Name (Legal Business Name): HUSAM MOURTADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 BOILING SPRINGS RD SUITE 1800
SPARTANBURG SC
29303-4201
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-560-9646
  • Fax:
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number26527
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: