Healthcare Provider Details

I. General information

NPI: 1003070194
Provider Name (Legal Business Name): EMAD Y MOUSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 HOSPITAL DR STE 200
LOGAN WV
25601-3451
US

IV. Provider business mailing address

PO BOX 119
LOGAN WV
25601
US

V. Phone/Fax

Practice location:
  • Phone: 304-896-5200
  • Fax: 304-896-5300
Mailing address:
  • Phone: 304-896-5200
  • Fax: 304-896-5300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number24508
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35092078
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number24508
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: