Healthcare Provider Details

I. General information

NPI: 1245294107
Provider Name (Legal Business Name): ALFRED RANDALL MOSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PROFESSIONAL PARK
GAFFNEY SC
29340-2319
US

IV. Provider business mailing address

101 PROFESSIONAL PARK
GAFFNEY SC
29340-2319
US

V. Phone/Fax

Practice location:
  • Phone: 864-489-1446
  • Fax: 864-489-4909
Mailing address:
  • Phone: 864-489-1446
  • Fax: 864-489-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number009903
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: