Provider Demographics
NPI:1558348508
Name:KHOLOUSSY, ABDELMOHSEN (MD)
Entity Type:Individual
Prefix:
First Name:ABDELMOHSEN
Middle Name:
Last Name:KHOLOUSSY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:A. MOHSEN
Other - Middle Name:
Other - Last Name:KHOLOUSSY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:14 COTTAGE HL E
Mailing Address - Street 2:POB 1184
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-1931
Mailing Address - Country:US
Mailing Address - Phone:570-622-5885
Mailing Address - Fax:
Practice Address - Street 1:14 COTTAGE HL E
Practice Address - Street 2:POB 1184
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-1931
Practice Address - Country:US
Practice Address - Phone:570-622-5885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-37201-L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA826664Medicaid
PA826664Medicaid
126435DX6Medicare ID - Type Unspecified