Healthcare Provider Details

I. General information

NPI: 1629415567
Provider Name (Legal Business Name): MICHAEL J MOSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2013
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD OHSU DEPARTMENT OF EMERGENCY MEDICINE MAIL CODE: CDW-EM
PORTLAND OR
97239
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD OHSU DEPARTMENT OF EMERGENCY MEDICINE MAIL CODE: CDW-EM
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number10814527-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD176626
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: