Provider Demographics
NPI:1033310206
Name:GORDONSVILLE CLINIC
Entity Type:Organization
Organization Name:GORDONSVILLE CLINIC
Other - Org Name:DR. ANGELA MOSS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-683-1070
Mailing Address - Street 1:126 JMZ DR
Mailing Address - Street 2:
Mailing Address - City:GORDONSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38563-2152
Mailing Address - Country:US
Mailing Address - Phone:615-683-1070
Mailing Address - Fax:615-683-1079
Practice Address - Street 1:126 JMZ DR
Practice Address - Street 2:
Practice Address - City:GORDONSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38563-2152
Practice Address - Country:US
Practice Address - Phone:615-683-1070
Practice Address - Fax:615-683-1079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3874872Medicaid
TN3874872Medicare ID - Type Unspecified
TN3874872Medicaid