Healthcare Provider Details

I. General information

NPI: 1629496260
Provider Name (Legal Business Name): KELLY FISHER MOYER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 S EUTAW ST STE 500
BALTIMORE MD
21201-1619
US

IV. Provider business mailing address

16 S EUTAW ST STE 500
BALTIMORE MD
21201-1619
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-0972
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberD0089987
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: