1164404133 NPI number — DR. BARRY M MOSS MD

Table of content: DR. BARRY M MOSS MD (NPI 1164404133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164404133 NPI number — DR. BARRY M MOSS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSS
Provider First Name:
BARRY
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164404133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30840 NORTHWESTERN HWY
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-932-1250
Provider Business Mailing Address Fax Number:
248-932-8977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30840 NORTHWESTERN HWY
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
FARMINGTON HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-932-1250
Provider Business Practice Location Address Fax Number:
248-932-8977
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301035120 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 700F319250 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1164404133 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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