Provider Demographics
NPI:1134274582
Name:MOSS, CHARLES M (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
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 1:240 WILLIAMSON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-3674
Mailing Address - Country:US
Mailing Address - Phone:908-994-5480
Mailing Address - Fax:908-994-8802
Practice Address - Street 1:240 WILLIAMSON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-3674
Practice Address - Country:US
Practice Address - Phone:908-994-5480
Practice Address - Fax:908-994-8802
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA298722086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ461523CB6Medicare PIN
C56294Medicare UPIN