Provider Demographics
NPI:1356760136
Name:MOSER, MARIE ADELE (MD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ADELE
Last Name:MOSER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3361
Mailing Address - Country:US
Mailing Address - Phone:252-384-2610
Mailing Address - Fax:
Practice Address - Street 1:112 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3361
Practice Address - Country:US
Practice Address - Phone:252-384-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101265178207V00000X
NC201511390200000X
NC2018-01205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1356760136Medicaid