Basic Information
| Provider Information | |||||||||
| NPI: | 1255308599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOURSI | ||||||||
| FirstName: | HOUSAM | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443660 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 AVENUE F NE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632931121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OS0007173 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 379672800 | 05 | FL | MEDICAID | P00346990 | 01 | RR MCR | OTHER | 57301 | 01 | FL | BCBS | OTHER |