Provider Demographics
NPI:1548245632
Name:MOSS, ELLIOTTE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTTE
Middle Name:
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 1:30840 TELEGRAPH ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2555
Mailing Address - Country:US
Mailing Address - Phone:248-932-8725
Mailing Address - Fax:248-932-8977
Practice Address - Street 1:30840 TELEGRAPH ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2555
Practice Address - Country:US
Practice Address - Phone:248-932-8725
Practice Address - Fax:248-932-8977
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029998207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F319250OtherBLUE SHIELD
MI1548245632Medicaid
MIA73892Medicare UPIN
MI0N53930004Medicare PIN