Basic Information
| Provider Information | |||||||||
| NPI: | 1013908532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSBY | ||||||||
| FirstName: | GERARD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 999360 PO BOX 33738 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482323738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107205715 | ||||||||
| FaxNumber: | 8107320891 | ||||||||
| Practice Location | |||||||||
| Address1: | 10201 E JEFFERSON AVE | ||||||||
| Address2: | SUITE 201A | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482143149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138213777 | ||||||||
| FaxNumber: | 3138243777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301051836 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2673288 | 05 | MI | MEDICAID | 4502397 | 05 | MI | MEDICAID |