Provider Demographics
NPI:1639290976
Name:MOSS, PERCY CLEOPHUS JR (MD)
Entity Type:Individual
Prefix:
First Name:PERCY
Middle Name:CLEOPHUS
Last Name:MOSS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:864 S LAFLIN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4026
Mailing Address - Country:US
Mailing Address - Phone:312-666-2455
Mailing Address - Fax:312-226-2258
Practice Address - Street 1:3435 W VAN BUREN ST
Practice Address - Street 2:SUITE A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-3312
Practice Address - Country:US
Practice Address - Phone:773-722-0013
Practice Address - Fax:312-226-2258
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL3643944207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology