1881075372 NPI number — MICHAEL MORIARTY D.O

Table of content: MICHAEL MORIARTY D.O (NPI 1881075372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881075372 NPI number — MICHAEL MORIARTY D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORIARTY
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O
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:
1881075372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 W STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19063-2620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-565-8600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 W STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-565-8600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2015

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: 207Q00000X , with the licence number:  63504 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: OS019260 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0000X , with the licence number: 63504 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 63504 . This is a "CT STATE LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".