=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790751402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HERBERT J. MOSBERG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2006
-----------------------------------------------------
Last Update Date | 09/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18904 HILLSIDE AVE
-----------------------------------------------------
City | HOLLIS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11423-1938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-740-5545
-----------------------------------------------------
Fax | 718-740-1551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 27842
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10087-7842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-670-1651
-----------------------------------------------------
Fax | 718-740-1551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 109340
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------