Provider Demographics
NPI:1619979291
Name:MOSBERG, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:MOSBERG
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 1:5 FOXBORO DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1939
Mailing Address - Country:US
Mailing Address - Phone:304-295-5949
Mailing Address - Fax:
Practice Address - Street 1:1106 COLEGATE DR
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1323
Practice Address - Country:US
Practice Address - Phone:740-568-2000
Practice Address - Fax:740-568-2096
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053594207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0056602000Medicaid
OH0501488Medicaid
OH0501488Medicaid