1093879009 NPI number — NEW MOON MEDICAL, INC

Table of content: (NPI 1093879009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093879009 NPI number — NEW MOON MEDICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW MOON MEDICAL, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1093879009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 331
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40392-0331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-737-5154
Provider Business Mailing Address Fax Number:
877-737-1881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 W LEXINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40391-1127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-737-5154
Provider Business Practice Location Address Fax Number:
877-737-1881
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WORTHINGTON
Authorized Official First Name:
BEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
859-737-5154

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  184257 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1865915 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 393322 . This is a "ANTHEM PROVIDER #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 90012758 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7436866 . This is a "AETNA PIN #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: D 5624460001 . This is a "UNITED AMERICAN INSURANCE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com