Provider Demographics
NPI:1154656882
Name:MOUSSA, TAREK (MD)
Entity Type:Individual
Prefix:
First Name:TAREK
Middle Name:
Last Name:MOUSSA
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 1:4437 STATE ROUTE 159
Mailing Address - Street 2:STE 125
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-7065
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:4437 STATE ROUTE 159 STE 125
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-7065
Practice Address - Country:US
Practice Address - Phone:740-779-4570
Practice Address - Fax:740-779-4579
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35095949207RC0000X
OH35.095949207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3101002Medicaid
WV3810018548Medicaid
OHP00931604OtherRRMCR
OH000000669833OtherANTHEM
OH000000696921OtherANTHEM
OH000000696921OtherANTHEM
OH7420221Medicare PIN