Basic Information
| Provider Information | |||||||||
| NPI: | 1851724256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BILLY H MOSES JR MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 407 | ||||||||
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| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304750407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125374986 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2400 BELLEVUE RD | ||||||||
| Address2: | #11 ERIN OFFICE PARK | ||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782752454 | ||||||||
| FaxNumber: | 4782750991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 09/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | OSTEEN | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9125385314 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEAST PRIMARY CARE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003138212A | 05 | GA | MEDICAID |