Provider Demographics
NPI:1043366735
Name:MOSHER, KEITH ALDEN JR (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALDEN
Last Name:MOSHER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:21 MERIDIAN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-5900
Mailing Address - Country:US
Mailing Address - Phone:731-256-0526
Mailing Address - Fax:731-256-1720
Practice Address - Street 1:21 MERIDIAN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301
Practice Address - Country:US
Practice Address - Phone:731-256-0526
Practice Address - Fax:731-256-1720
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24751207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3078643Medicaid
TNF68003Medicare UPIN
TN3078643Medicaid