Healthcare Provider Details

I. General information

NPI: 1568416378
Provider Name (Legal Business Name): THEA C. MORAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 FILLINGIM ST MASTIN BLDG 617
MOBILE AL
36617-2238
US

IV. Provider business mailing address

3700 CARLYLE CLOSE 897
MOBILE AL
36609-1871
US

V. Phone/Fax

Practice location:
  • Phone: 251-470-5842
  • Fax: 251-470-5809
Mailing address:
  • Phone: 251-342-4295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number20112
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: