Basic Information
| Provider Information | |||||||||
| NPI: | 1659668721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSES | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91498 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366911498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514600326 | ||||||||
| FaxNumber: | 2514602846 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 MOBILE INFIRMARY CIR | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366073513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514600326 | ||||||||
| FaxNumber: | 2514602846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2011 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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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 | 207ZP0102X | 33236 | AL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 174460 | 05 | AL | MEDICAID | 511-63913 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |