Healthcare Provider Details

I. General information

NPI: 1710908728
Provider Name (Legal Business Name): MOSS & GEUDER SURGICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE SUITE 707
HACKENSACK NJ
07601-1997
US

IV. Provider business mailing address

20 PROSPECT AVE SUITE 707
HACKENSACK NJ
07601-1997
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-2220
  • Fax: 201-343-9106
Mailing address:
  • Phone: 201-488-2220
  • Fax: 201-343-9106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA29872
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier550660
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. CHARLES MICHAEL MOSS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-488-2220