Basic Information
| Provider Information | |||||||||
| NPI: | 1306993985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | QUINTON | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 FAIRGROVE AVE STE E | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450111930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138680055 | ||||||||
| FaxNumber: | 5132977577 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 FAIRGROVE AVE STE E | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450111930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138680055 | ||||||||
| FaxNumber: | 5132977577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35082846 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1225260888 | 01 | OH | NPI | OTHER | 2444144 | 05 | OH | MEDICAID |