Provider Demographics
NPI:1275845208
Name:MOSS, JIMMY L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:L
Last Name:MOSS
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:800-862-9980
Mailing Address - Fax:314-362-1185
Practice Address - Street 1:12634 OLIVE BLVD
Practice Address - Street 2:DEPT ANESTHESIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6337
Practice Address - Country:US
Practice Address - Phone:800-862-9980
Practice Address - Fax:314-362-1185
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2024-04-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2020009346207RC0200X, 207RC0200X
IL036143163207R00000X, 207RC0200X
FLME111403207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200045017Medicaid