1245451202 NPI number — MICAH MOOBERRY M.D.

Table of content: MICAH MOOBERRY M.D. (NPI 1245451202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245451202 NPI number — MICAH MOOBERRY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOOBERRY
Provider First Name:
MICAH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1245451202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
98 MANNING DRIVE, 323 MARY ELLEN JONES BUILDING
Provider Second Line Business Mailing Address:
CB # 7035
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27599-7035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-966-3311
Provider Business Mailing Address Fax Number:
919-966-7639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 MANNING DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27514-4220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-966-4131
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2007

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: 2080P0207X , with the licence number:  2008-00585 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0000X , with the licence number: 2008-00585 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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