Healthcare Provider Details

I. General information

NPI: 1801922547
Provider Name (Legal Business Name): DAVID RUSSELL MOSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 11/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WASHINGTON ST BOX 298
BOSTON MA
02111-1552
US

IV. Provider business mailing address

800 WASHINGTON ST BOX 298
BOSTON MA
02111-1552
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6044
  • Fax: 617-636-8384
Mailing address:
  • Phone: 617-636-6044
  • Fax: 617-636-8384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number239306
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number239306
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: