MEDICARE: DR. HUSAM MOURTADA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204C00000X	Sports Medicine (Neuromusculoskeletal Medicine) Physician	26527	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	067EJ	OTHER	NC	BCBS
3	D1678	OTHER	SC	MEDCOST
4	7806056	OTHER	SC	AETNA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114998671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HUSAM MOURTADA MD

Provider Business Mailing Address
First Line	:	PO BOX 743070
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3070
Country	:	US
Telephone Number	:	864-560-4304
Fax Number	:	864-560-4413

Provider Business Practice Location Address
First Line	:	1330 BOILING SPRINGS RD
Second Line	:	SUITE 1800
City	:	SPARTANBURG
State	:	SC
Zip	:	29303-4201
Country	:	US
Telephone Number	:	864-560-9646
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2006
Last Update Date	:	01/27/2021

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