Healthcare Provider Details

I. General information

NPI: 1689659880
Provider Name (Legal Business Name): MICHAEL A MOELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

2082 BLUESTREAM CT
DAYTON OH
45459-7500
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-8000
  • Fax:
Mailing address:
  • Phone: 937-286-1662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35062607M
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.062607
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: