Healthcare Provider Details

I. General information

NPI: 1174567804
Provider Name (Legal Business Name): ROBERT EDWARD MOSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD VA ROSEBURG/SPECIALTY CLINIC
ROSEBURG OR
97471-6523
US

IV. Provider business mailing address

913 NW GARDEN VALLEY BLVD VA ROSEBURG HCS
ROSEBURG OR
97471-6523
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax: 541-677-3150
Mailing address:
  • Phone: 541-440-1000
  • Fax: 541-677-3150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD162031
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD00038999
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: