Provider Demographics
NPI:1780855221
Name:MOSS FOOT CLINIC PLLC
Entity Type:Organization
Organization Name:MOSS FOOT CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:734-427-7111
Mailing Address - Street 1:27501 WARREN RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-2253
Mailing Address - Country:US
Mailing Address - Phone:734-427-7111
Mailing Address - Fax:734-427-1377
Practice Address - Street 1:27501 WARREN RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2253
Practice Address - Country:US
Practice Address - Phone:734-427-7111
Practice Address - Fax:734-427-1377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001094213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5188247OtherAETNA
MI=========OtherPPOM
MIT97184Medicare UPIN
MI0P54500Medicare PIN