Provider Demographics
NPI:1265539050
Name:MOUSAW, CHRISTIE O (DO)
Entity type:Individual
Prefix:DR
First Name:CHRISTIE
Middle Name:O
Last Name:MOUSAW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CHRISTIE
Other - Middle Name:LYNN
Other - Last Name:O'NEILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 EVERGREEN DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-1059
Mailing Address - Country:US
Mailing Address - Phone:610-579-3555
Mailing Address - Fax:610-579-3566
Practice Address - Street 1:300 EVERGREEN DR
Practice Address - Street 2:SUITE 310
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-1059
Practice Address - Country:US
Practice Address - Phone:610-579-3564
Practice Address - Fax:610-579-3566
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS 012760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101720742Medicaid
PAI65620Medicare UPIN
PA101720742Medicaid