Healthcare Provider Details

I. General information

NPI: 1710418546
Provider Name (Legal Business Name): MATTHEW C MOSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST STE 301
JACKSON MS
39202-1687
US

IV. Provider business mailing address

501 MARSHALL ST STE 301
JACKSON MS
39202-1687
US

V. Phone/Fax

Practice location:
  • Phone: 601-353-9900
  • Fax: 601-353-3654
Mailing address:
  • Phone: 13-539-9006
  • Fax: 601-353-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number29978
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number39978
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: