=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104243633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOVASCULAR SERVICES OF DR TAREK MOUSA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2014
-----------------------------------------------------
Last Update Date | 09/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2427 STEINWAY ST
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-3654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-208-0080
-----------------------------------------------------
Fax | 929-208-0010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2427 STEINWAY STREET
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-208-0080
-----------------------------------------------------
Fax | 929-208-0010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TAREK M MOUSA
-----------------------------------------------------
Credential | MD, PHD
-----------------------------------------------------
Telephone | 347-556-7769
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 259363
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------