Basic Information
| Provider Information | |||||||||
| NPI: | 1578547618 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSELEY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | HART | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844555 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022844555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408918730 | ||||||||
| FaxNumber: | 5408915742 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 KINGSLEY LN | ||||||||
| Address2: | #305 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235054614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578895422 | ||||||||
| FaxNumber: | 7578895450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 07/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101052980 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7217404 | 05 | VA | MEDICAID | 1578547618 | 05 | VA | MEDICAID |