Provider Demographics
NPI:1619961232
Name:MOUSHMOUSH, BASSAM (MD)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:
Last Name:MOUSHMOUSH
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 1:1211 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8707
Mailing Address - Country:US
Mailing Address - Phone:304-757-4694
Mailing Address - Fax:304-757-4695
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:SUITE 331
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1619
Practice Address - Country:US
Practice Address - Phone:304-347-2042
Practice Address - Fax:304-347-2091
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16432207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0073986000Medicaid
WV0073986000Medicaid
0709053Medicare ID - Type Unspecified