=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487868964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSHUA A MOU MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 12/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11101 N SHERMAN RD
-----------------------------------------------------
City | EDGERTON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53534-9002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-884-1695
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5216 NANNYBERRY DR
-----------------------------------------------------
City | FITCHBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53711-7649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-209-9817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 64329-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 036119850
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------