1225338148 NPI number — BRAD MORIARTY OD PC

Table of content: (NPI 1225338148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225338148 NPI number — BRAD MORIARTY OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAD MORIARTY OD PC
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:
1225338148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 MOUNT RUSHMORE RD
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
RAPID CITY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57701-4588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-343-4164
Provider Business Mailing Address Fax Number:
605-348-9773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 MOUNT RUSHMORE RD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
RAPID CITY
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57701-4588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-343-4164
Provider Business Practice Location Address Fax Number:
605-348-9773
Provider Enumeration Date:
10/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MORIARTY
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
JEROME
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
605-343-4164

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  T484 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: S104430 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9202310 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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