MEDICARE: KATHLEEN M. MOSS GRIZZARD 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	207R00000X	Internal Medicine Physician	ME33818	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110178342	OTHER	FL	RAILROAD
2	00004389	OTHER	FL	UNITED
3	30475	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1770593923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN M. MOSS GRIZZARD MD

Provider Business Mailing Address
First Line	:	4108 HENDERSON BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5750
Country	:	US
Telephone Number	:	813-289-4321
Fax Number	:	813-287-2949

Provider Business Practice Location Address
First Line	:	4108 HENDERSON BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5750
Country	:	US
Telephone Number	:	813-289-4321
Fax Number	:	813-287-2949

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	01/24/2012

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