Provider Demographics
NPI:1164879359
Name:MD MASSOUD LLC
Entity Type:Organization
Organization Name:MD MASSOUD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-475-8700
Mailing Address - Street 1:152 WYNDERMERE DRIVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905
Mailing Address - Country:US
Mailing Address - Phone:814-535-7576
Mailing Address - Fax:814-536-1369
Practice Address - Street 1:321 MAIN ST
Practice Address - Street 2:SUITE 3G
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1632
Practice Address - Country:US
Practice Address - Phone:814-535-7576
Practice Address - Fax:814-536-1369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty