Provider Demographics
NPI:1154789436
Name:RICHARD MOSS MD
Entity type:Organization
Organization Name:RICHARD MOSS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:YUCATONIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:812-634-6666
Mailing Address - Street 1:721 W 13TH ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1855
Mailing Address - Country:US
Mailing Address - Phone:812-634-6666
Mailing Address - Fax:812-634-6669
Practice Address - Street 1:721 W 13TH ST
Practice Address - Street 2:SUITE 208
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1855
Practice Address - Country:US
Practice Address - Phone:812-634-6666
Practice Address - Fax:812-634-6669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039795A261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN207Y00000XMedicaid