Healthcare Provider Details

I. General information

NPI: 1154789436
Provider Name (Legal Business Name): RICHARD MOSS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W 13TH ST SUITE 208
JASPER IN
47546-1855
US

IV. Provider business mailing address

721 W 13TH ST SUITE 208
JASPER IN
47546-1855
US

V. Phone/Fax

Practice location:
  • Phone: 812-634-6666
  • Fax: 812-634-6669
Mailing address:
  • Phone: 812-634-6666
  • Fax: 812-634-6669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number01039795A
License Number StateIN

VIII. Authorized Official

Name: LISA YUCATONIS
Title or Position: OFFICE MANAGER
Credential: LPN
Phone: 812-634-6666