Provider Demographics
NPI:1467563429
Name:MOUSSA, BASEL (MD)
Entity Type:Individual
Prefix:
First Name:BASEL
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 450615
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145
Mailing Address - Country:US
Mailing Address - Phone:440-356-6666
Mailing Address - Fax:440-356-6651
Practice Address - Street 1:20997 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44176
Practice Address - Country:US
Practice Address - Phone:440-356-6666
Practice Address - Fax:440-356-6651
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-09-07
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-09-07
Provider Licenses
StateLicense IDTaxonomies
OH35-071087174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000152232OtherANTHEM BLUE CROSS
OH522125821OtherPROVIDER NUMBER
OH0852635Medicaid
OH522125821026OtherCARESOURCE
OHMO0867082Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
OH060050097Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
OH522125821026OtherCARESOURCE
OHF01687Medicare UPIN
OH522125821OtherPROVIDER NUMBER
0867083Medicare PIN