Provider Demographics
NPI:1912978172
Name:MOSS, ROY L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:L
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ROY
Other - Middle Name:LAURENCE
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6610
Practice Address - Fax:617-638-6616
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4344032085B0100X, 2085N0904X, 2085R0204X
FLME1006702085R0202X
MDD00634052085R0202X
MA2110842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110161078AMedicaid
PA206126OtherJOHNS HOPKINS
MD408338500Medicaid
DC2849OtherB/C B/S
NH3139893Medicaid
MDJ062OtherB/C B/S
PA2083615OtherHIGHMARK BLUE SHIELD
PA102248052Medicaid
PA1578951OtherGATEWAY-WMG
MDKA80OtherB/C B/S
DEDD4343Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MD408338500Medicaid
MD017614A00Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 99
PA102248052Medicaid
MDKA80OtherB/C B/S
MD434LL964Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 01
PA206126OtherJOHNS HOPKINS
MDCN2566Medicare ID - Type UnspecifiedRAILROAD MEDICARE