Healthcare Provider Details

I. General information

NPI: 1356513873
Provider Name (Legal Business Name): ANTONIO MORAN JR MD FACP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 STARLING ST SUITE 303
BRUNSWICK GA
31520-4265
US

IV. Provider business mailing address

2500 STARLING ST SUITE 303
BRUNSWICK GA
31520-4265
US

V. Phone/Fax

Practice location:
  • Phone: 912-261-4998
  • Fax: 912-261-4741
Mailing address:
  • Phone: 912-261-4998
  • Fax: 912-261-4741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number034669
License Number StateGA

VIII. Authorized Official

Name: MRS. PAMELA BENNETT
Title or Position: OFFICE MANAGER
Credential:
Phone: 912-261-4998