Provider Demographics
NPI:1265474159
Name:MOSLEY, EDWARD L (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:L
Last Name:MOSLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:980 HIGHWAY 28
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347-3695
Mailing Address - Country:US
Mailing Address - Phone:423-942-8262
Mailing Address - Fax:423-942-8292
Practice Address - Street 1:980 HIGHWAY 28
Practice Address - Street 2:SUITE 203
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3695
Practice Address - Country:US
Practice Address - Phone:423-942-8262
Practice Address - Fax:423-942-8292
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238143207QG0300X, 208600000X, 208D00000X
FLME94903207QG0300X, 208600000X, 208D00000X
DCMD8257207QG0300X, 208D00000X, 208600000X
MDD0021954207QG0300X, 208600000X, 208D00000X
TNMD0000049564207QG0300X, 208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2754OtherBLUE CROSS BLUE SHIELD
MD6199OtherBLUE CROSS BLUE SHIELD
0495776OtherAETNA HEALTH MGMNT, LLC
112505OtherAARP
8257207750000OtherTRICARE
DC2754OtherBLUE CROSS BLUE SHIELD
DC116726Medicare ID - Type UnspecifiedWASH DC & METRO AREA