Healthcare Provider Details

I. General information

NPI: 1639290976
Provider Name (Legal Business Name): PERCY CLEOPHUS MOSS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 W VAN BUREN ST SUITE A
CHICAGO IL
60624-3312
US

IV. Provider business mailing address

864 S LAFLIN ST
CHICAGO IL
60607-4026
US

V. Phone/Fax

Practice location:
  • Phone: 773-722-0013
  • Fax: 312-226-2258
Mailing address:
  • Phone: 312-666-2455
  • Fax: 312-226-2258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3643944
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: