Provider Demographics
NPI:1346225406
Name:MOSS, JACK J (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:J
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5901 TECHNOLOGY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-6013
Mailing Address - Country:US
Mailing Address - Phone:317-328-5050
Mailing Address - Fax:317-328-5053
Practice Address - Street 1:5901 TECHNOLOGY CENTER DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-6013
Practice Address - Country:US
Practice Address - Phone:317-328-5050
Practice Address - Fax:317-715-9965
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01030758A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000082122OtherANTHEM-351158723
IN000000492363OtherANTHEM 203778927
IN060963OtherHEALTH ALLIANCE-351158723
IN100369250Medicaid
IN002938OtherSIHO-351158723
INQ0084711OtherCMOSHO351158723&352047427
IN300100709OtherRR MEDICARE-351158723
IN300100709OtherRR MEDICARE-351158723
IN002938OtherSIHO-351158723