1134301377 NPI number — ANDREY YUREIVICH MOISEYEV III M.A.

Table of content: ANDREY YUREIVICH MOISEYEV III M.A. (NPI 1134301377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134301377 NPI number — ANDREY YUREIVICH MOISEYEV III M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOISEYEV
Provider First Name:
ANDREY
Provider Middle Name:
YUREIVICH
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
M.A.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134301377
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 FOUNTAIN ST
Provider Second Line Business Mailing Address:
P.O. BOX 1186, 47902
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47901-1731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-742-5046
Provider Business Mailing Address Fax Number:
765-477-9905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 SAW MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905-5592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-742-4848
Provider Business Practice Location Address Fax Number:
765-477-9905
Provider Enumeration Date:
11/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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