Provider Demographics
NPI:1003070194
Name:MOUSA, EMAD Y (MD)
Entity Type:Individual
Prefix:
First Name:EMAD
Middle Name:Y
Last Name:MOUSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601
Mailing Address - Country:US
Mailing Address - Phone:304-896-5200
Mailing Address - Fax:304-896-5300
Practice Address - Street 1:77 HOSPITAL DR STE 200
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3451
Practice Address - Country:US
Practice Address - Phone:304-896-5200
Practice Address - Fax:304-896-5300
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24508207QA0401X, 207VX0000X
OH35092078207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1003070194OtherWV MEDICARE
WV1003070194Medicaid
OH11865318OtherCAQH
OH2873029Medicaid
WV1003070194Medicaid