Healthcare Provider Details

I. General information

NPI: 1013908532
Provider Name (Legal Business Name): GERARD M MOSBY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 E JEFFERSON AVE SUITE 201A
DETROIT MI
48214-3149
US

IV. Provider business mailing address

DEPT 999360 PO BOX 33738
DETROIT MI
48232-3738
US

V. Phone/Fax

Practice location:
  • Phone: 313-821-3777
  • Fax: 313-824-3777
Mailing address:
  • Phone: 810-720-5715
  • Fax: 810-732-0891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301051836
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: