Healthcare Provider Details

I. General information

NPI: 1275526485
Provider Name (Legal Business Name): THOMAS M MORIARTY MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E GRAY ST SUITE 1105
LOUISVILLE KY
40202-3900
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-583-1609
  • Fax: 502-583-2120
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number33517
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: