Basic Information
| Provider Information | |||||||||
| NPI: | 1447307244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | RANDALL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 724 AUBREY BELL DR | ||||||||
| Address2: | |||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281055055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953550 | ||||||||
| FaxNumber: | 7042953556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Y00000X | 2010-00143 | NC | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 15857 | 01 | NC | BCBSNC | OTHER | 4678040 | 01 | NC | CIGNA HEALTHCARE | OTHER | 30083055 | 01 | SC | SELECT HEALTH OF SC | OTHER | 5914807 | 05 | NC | MEDICAID | 9733523 | 01 | NC | AETNA | OTHER | 000000306335 | 01 | SC | UNISON HEALTH PLAN OF SC | OTHER | P00866360 | 01 | NC | RAILROAD MEDICARE | OTHER | NC1193 | 05 | SC | MEDICAID |