Provider Demographics
NPI:1275640526
Name:MOSS, KELVIN JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELVIN
Middle Name:JERRY
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 SOUTHSIDE CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-5400
Mailing Address - Country:US
Mailing Address - Phone:706-636-6677
Mailing Address - Fax:706-636-6678
Practice Address - Street 1:1200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2529
Practice Address - Country:US
Practice Address - Phone:706-217-2207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 054634207Q00000X
GA054634208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA839374814GMedicaid
GA839374814GMedicaid
GAI 09371Medicare UPIN