Basic Information
| Provider Information | |||||||||
| NPI: | 1043366735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSHER | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ALDEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 MERIDIAN SPRINGS DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383015900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312560526 | ||||||||
| FaxNumber: | 7312561720 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 MERIDIAN SPRINGS DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312560526 | ||||||||
| FaxNumber: | 7312561720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 24751 | TN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 24751 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3078643 | 05 | TN | MEDICAID |