1912978172 NPI number — DR. ROY L MOSS M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912978172 NPI number — DR. ROY L MOSS M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MOSS

Provider First Name:

ROY

Provider Middle Name:

L

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

MOSS

Provider Other First Name:

ROY

Provider Other Middle Name:

LAURENCE

Provider Other Name Prefix Text:

DR.

Provider Other Name Suffix Text:

Provider Other Credential Text:

M.D.

Provider Other Last Name Type Code:

1

NPI Number:

1912978172

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

04/01/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

960 MASSACHUSETTS AVE

Provider Second Line Business Mailing Address:

FL 2

Provider Business Mailing Address City Name:

BOSTON

Provider Business Mailing Address State Name:

MA

Provider Business Mailing Address Postal Code:

02118-2690

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

840 HARRISON AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

BOSTON

Provider Business Practice Location Address State Name:

MA

Provider Business Practice Location Address Postal Code:

02118-2905

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

617-638-6610

Provider Business Practice Location Address Fax Number:

617-638-6616

Provider Enumeration Date:

01/27/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2085B0100X , with the licence number:  MD434403 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085N0904X , with the licence number: MD434403 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0202X , with the licence number: ME100670 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0202X , with the licence number: D0063405 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0204X , with the licence number: MD434403 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0202X , with the licence number: 211084 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 110161078A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
• Identifier: 206126 . This is a "JOHNS HOPKINS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 408338500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 2849 . This is a "B/C B/S" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
• Identifier: 3139893 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
• Identifier: J062 . This is a "B/C B/S" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 2083615 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 102248052 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1578951 . This is a "GATEWAY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: KA80 . This is a "B/C B/S" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 024427400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".