Organization
NORTHSIDE PEDIATRICS PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SANDRA DOTSON MOSS M.D. (PRESIDENT)
(270) 678-5740
Entity
Organization
Contact information
Practice address
290 OLD JACKSON HWY 31E LOOP, GLASGOW, KY 42141-9089
(270) 678-5740
Mailing address
290 OLD JACKSON HWY 31E LOOP, GLASGOW, KY 42141-9089
(270) 678-5740
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
19876
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000057724
BLUE CROSS BLUE SHIELD
KY
05
—
64198765
—
KY
Enumeration date
12/06/2006
Last updated
08/22/2020
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