Provider Demographics
NPI:1487684080
Name:MOSS, ROBERT JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAY
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 1:1775 BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1005
Mailing Address - Country:US
Mailing Address - Phone:847-318-2500
Mailing Address - Fax:847-318-2558
Practice Address - Street 1:901 NORTHWOODS RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-2222
Practice Address - Country:US
Practice Address - Phone:843-373-8453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059412207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059412Medicaid
ILL69140OtherMEDICARE ID
ILL69140OtherMEDICARE ID
ILL69387Medicare ID - Type Unspecified