Healthcare Provider Details

I. General information

NPI: 1265038681
Provider Name (Legal Business Name): MOEN, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 CALIFORNIA AVE TOWER B 2ND FLOOR
BAKERSFIELD CA
93309
US

IV. Provider business mailing address

50 S B B KING BLVD
MEMPHIS TN
38103-2626
US

V. Phone/Fax

Practice location:
  • Phone: 901-438-6200
  • Fax:
Mailing address:
  • Phone: 901-422-7644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY MANN
Title or Position: BILLING CREDENTIALING MANAGER
Credential:
Phone: 901-422-7608