Basic Information
| Provider Information | |||||||||
| NPI: | 1568690501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT L MOSS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2421 E SOUTHERN AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852827612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804252158 | ||||||||
| FaxNumber: | 4808394727 | ||||||||
| Practice Location | |||||||||
| Address1: | 2421 E SOUTHERN AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852827612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804252158 | ||||||||
| FaxNumber: | 4808394727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 08/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | MOSS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4804252158 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 14008 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | ZMD14008 | 01 | AZ | MEDICARE | OTHER | 228058 AZ | 05 | AZ | MEDICAID |