1114584125 NPI number — MOSS RESTORATIVE FOOT & ANKLE CENTER, PLLC

Table of content: (NPI 1114584125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114584125 NPI number — MOSS RESTORATIVE FOOT & ANKLE CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSS RESTORATIVE FOOT & ANKLE CENTER, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOSS PODIATRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114584125
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40002
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33743-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-302-9500
Provider Business Mailing Address Fax Number:
727-302-9504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7855 38TH AVE N STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33710-1134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-302-9500
Provider Business Practice Location Address Fax Number:
727-302-9504
Provider Enumeration Date:
05/24/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MOSS
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
727-641-2999

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 340659800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65963 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: T89762 . This is a "UPIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1039020500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 213E00000X . This is a "TAXONOMY CODE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 213ES0103X . This is a "TAXONOMY CODE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 11429703 . This is a "CAQH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 103920500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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