Provider Demographics
NPI:1407920911
Name:MOSS, HERSHEL S (MD)
Entity Type:Individual
Prefix:
First Name:HERSHEL
Middle Name:S
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 1:4008 CALGARY CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2798
Mailing Address - Country:US
Mailing Address - Phone:734-668-6462
Mailing Address - Fax:734-369-3369
Practice Address - Street 1:4008 CALGARY CT
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2798
Practice Address - Country:US
Practice Address - Phone:734-668-6462
Practice Address - Fax:734-369-3369
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2009-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI046203207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI424098110Medicaid
HM046203OtherCOMMERCIAL-COMMERCIAL NUMBER
010H262530OtherBLUE CROSS-BLUE CROSS
HM046203OtherCHAMPUS-CHAMPUS
D42355Medicare UPIN
HM046203OtherCHAMPUS-CHAMPUS