Provider Demographics
NPI:1174703250
Name:MOSS, SEABORN THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:SEABORN
Middle Name:THOMAS
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 REDMOND CIR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1322
Mailing Address - Country:US
Mailing Address - Phone:706-232-6010
Mailing Address - Fax:706-234-4971
Practice Address - Street 1:2016 REDMOND CIR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1322
Practice Address - Country:US
Practice Address - Phone:706-232-6010
Practice Address - Fax:706-234-4971
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000428304BMedicaid
GAP00650906OtherRR MEDICARE
GA511I080474Medicare PIN
GA000428304BMedicaid