Provider Demographics
NPI:1306003603
Name:KELVIN MOSS MD PC
Entity Type:Organization
Organization Name:KELVIN MOSS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-636-6677
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:
Practice Address - Street 1:83 SOUTHSIDE CHURCH ST
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-5400
Practice Address - Country:US
Practice Address - Phone:706-636-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 054634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
511G700632Medicare PIN