Basic Information
| Provider Information | |||||||||
| NPI: | 1447284120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSES | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOSES | ||||||||
| OtherFirstName: | BILL | ||||||||
| OtherMiddleName: | H | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2400 BELLEVUE RD STE 11 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782752454 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2400 BELLEVUE RD STE 11 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782752454 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 025237 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 053173282A | 01 | GA | MEDICAID GROUP | OTHER | 000280541D | 05 | GA | MEDICAID |