=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316413560
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN ENDOCRINOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2018
-----------------------------------------------------
Last Update Date | 10/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 THOMAS RD STE 113
-----------------------------------------------------
City | WEST MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71291-7365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-387-3453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2026 ROSEDOWN DR
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-3083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | DR. MOHAMMAD MOUSA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 318-387-3453
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------