=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093100323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN A MOSS MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2015
-----------------------------------------------------
Last Update Date | 04/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6230 SCOTT ST 111
-----------------------------------------------------
City | PUNTA GORDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33950-3939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-637-5780
-----------------------------------------------------
Fax | 941-627-5765
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6230 SCOTT ST 111
-----------------------------------------------------
City | PUNTA GORDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33950-3939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-637-5780
-----------------------------------------------------
Fax | 941-627-5765
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN A MOSS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 941-637-5780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | ME84424
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------