Healthcare Provider Details

I. General information

NPI: 1962542456
Provider Name (Legal Business Name): JEFFREY MARK MOSEMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

1800 E 2ND ST
BLOOMINGTON IN
47401-5224
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-1625
  • Fax: 812-855-4628
Mailing address:
  • Phone: 812-331-7717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01031093
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: