Healthcare Provider Details

I. General information

NPI: 1609003391
Provider Name (Legal Business Name): MATTHEW DAVID MOSLENER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S 3RD ST SUITE 400
BELLEVILLE IL
62220
US

IV. Provider business mailing address

1037 YALE AVE
RICHMOND HEIGHTS MO
63117-1820
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.124277
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number125-057058
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: