MEDICARE: DOUGLAS MOSS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	41178	GA
2	207P00000X	Emergency Medicine Physician	ME58453	FL
3	207P00000X	Emergency Medicine Physician	1870621	NY
4	207R00000X	Internal Medicine Physician	041178	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110177668	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	525985740	OTHER	GA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1679542781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS MOSS MD

Provider Business Mailing Address
First Line	:	814 NORTHWOOD PARK DR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-1398
Country	:	US
Telephone Number	:	229-259-0032
Fax Number	:	229-259-0068

Provider Business Practice Location Address
First Line	:	814 NORTHWOOD PARK DR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-1398
Country	:	US
Telephone Number	:	229-259-0032
Fax Number	:	229-259-0068

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	06/21/2010

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Directions to “ DOUGLAS MOSS MD” Practice Location

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