Provider Demographics
NPI:1801914858
Name:MARILYN C. MOSS, M.D.
Entity type:Organization
Organization Name:MARILYN C. MOSS, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-752-7100
Mailing Address - Street 1:3210 N WICKHAM RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2300
Mailing Address - Country:US
Mailing Address - Phone:321-752-7100
Mailing Address - Fax:321-752-7105
Practice Address - Street 1:3210 N WICKHAM RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2300
Practice Address - Country:US
Practice Address - Phone:321-752-7100
Practice Address - Fax:321-752-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME22466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4137Medicare ID - Type UnspecifiedGROUP ID