Healthcare Provider Details

I. General information

NPI: 1508022526
Provider Name (Legal Business Name): AMOS MICHAEL MOBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 04/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6044 MAIN ST SUITE 100
WILLIAMSVILLE NY
14221-6883
US

IV. Provider business mailing address

6044 MAIN ST SUITE 100
WILLIAMSVILLE NY
14221-6883
US

V. Phone/Fax

Practice location:
  • Phone: 716-633-6988
  • Fax: 716-631-8690
Mailing address:
  • Phone: 716-633-6988
  • Fax: 716-631-8690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number253761
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: