Provider Demographics
NPI:1568038800
Name:MOUSSA, MUTASEM (MA)
Entity Type:Individual
Prefix:
First Name:MUTASEM
Middle Name:
Last Name:MOUSSA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9830 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2667
Mailing Address - Country:US
Mailing Address - Phone:708-642-6457
Mailing Address - Fax:
Practice Address - Street 1:9830 RIDGELAND AVE STE 9A
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2668
Practice Address - Country:US
Practice Address - Phone:708-642-6457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty