MEDICARE: DR. MARILYN CAROL MOSS M.D.

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	207Q00000X	Family Medicine Physician	ME22466	FL

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

General Provider Information

NPI Number	:	1962405126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARILYN CAROL MOSS M.D.

Provider Business Mailing Address
First Line	:	2100 N WICKHAM RD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-8110
Country	:	US
Telephone Number	:	321-752-7100
Fax Number	:	321-752-7105

Provider Business Practice Location Address
First Line	:	2100 N WICKHAM RD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-8110
Country	:	US
Telephone Number	:	321-752-7100
Fax Number	:	321-752-7105

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	03/20/2013

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