Organization
KEITH A. MOSS, M.D., SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KEITH A. MOSS M.D. (PRESIDENT)
(815) 935-2784
Entity
Organization
Contact information
Practice address
300 RIVERSIDE DR, SUITE 2400, BOURBONNAIS, IL 60914-4996
(815) 935-2784
(815) 935-5687
Mailing address
300 RIVERSIDE DR, SUITE 2400, BOURBONNAIS, IL 60914-4996
(815) 935-2784
(815) 935-5687
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036105851
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036105851
—
IL
Enumeration date
07/11/2007
Last updated
05/28/2008
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