Healthcare Provider Details

I. General information

NPI: 1770699555
Provider Name (Legal Business Name): BRAD ROBERT MOSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 PRAIRIE CENTER DR SUITE 250
EDEN PRAIRIE MN
55344-7314
US

IV. Provider business mailing address

6465 WAYZATA BLVD SUITE 900
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-944-2519
  • Fax: 952-944-0460
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number44775
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: