Healthcare Provider Details

I. General information

NPI: 1497283352
Provider Name (Legal Business Name): ALPHA OMEGA MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 HOSPITAL DR
LOGAN WV
25601-3451
US

IV. Provider business mailing address

PO BOX 119
LOGAN WV
25601-0119
US

V. Phone/Fax

Practice location:
  • Phone: 304-400-6262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EMAD MOUSA
Title or Position: DOCTOR
Credential: MD
Phone: 304-896-5200