Provider Demographics
NPI:1235593161
Name:MOSELEY, MARY MONTGOMERY BOURKE (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MONTGOMERY BOURKE
Last Name:MOSELEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BOURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3411 WAYNE AVE FL 6
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2552
Mailing Address - Country:US
Mailing Address - Phone:610-304-8066
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-6626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304487207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine