Healthcare Provider Details

I. General information

NPI: 1053435321
Provider Name (Legal Business Name): FRED M MOESLEIN MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CAMPUS VIEW BLVD STE 100
COLUMBUS OH
43235-8628
US

IV. Provider business mailing address

100 E CAMPUS VIEW BLVD STE 100
COLUMBUS OH
43235-8628
US

V. Phone/Fax

Practice location:
  • Phone: 614-384-7177
  • Fax: 614-947-8309
Mailing address:
  • Phone: 614-384-7177
  • Fax: 614-947-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD431732
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD431732
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35.087689
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: