Provider Demographics
NPI:1407891708
Name:MOUSSA, SAMIR (MD)
Entity Type:Individual
Prefix:
First Name:SAMIR
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:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6622
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:7206 MARKET ST
Practice Address - Street 2:SUITE A
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4507
Practice Address - Country:US
Practice Address - Phone:330-726-3379
Practice Address - Fax:330-726-8683
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039456L208D00000X
OH35054126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2673914Medicaid
PA1023242700001Medicaid
OHF48885Medicare UPIN
PA1023242700001Medicaid
OHMO4182181Medicare PIN