Provider Demographics
NPI:1134563869
Name:MOSS, EMMA BAKER (MD)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:BAKER
Last Name:MOSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:BAKER
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:401 W MICHIGAN ST APT 1114
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2821
Mailing Address - Country:US
Mailing Address - Phone:850-459-0605
Mailing Address - Fax:
Practice Address - Street 1:MILWAUKEE RADIOLOGISTS, LTD.
Practice Address - Street 2:6150 W. LAYTON AVE
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53129
Practice Address - Country:US
Practice Address - Phone:414-914-9430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI73851-202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty