1821298761 NPI number — MOSHA MASHAUN PETERS-HARRIS M.D.

Table of content: MOSHA MASHAUN PETERS-HARRIS M.D. (NPI 1821298761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821298761 NPI number — MOSHA MASHAUN PETERS-HARRIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERS-HARRIS
Provider First Name:
MOSHA
Provider Middle Name:
MASHAUN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERS
Provider Other First Name:
MOSHA
Provider Other Middle Name:
MASHAUN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821298761
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11868 COLLEGE BACKBONE ROAD
Provider Second Line Business Mailing Address:
HAZEL HALL, #1062
Provider Business Mailing Address City Name:
PRINCESS ANNE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-651-8452
Provider Business Mailing Address Fax Number:
410-651-7586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 PARKSIDE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERLIN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21811-1635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-251-1551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  D70961 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009910748 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009910689 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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