Healthcare Provider Details

I. General information

NPI: 1386035954
Provider Name (Legal Business Name): TIM I MOOMAW NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 02/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

IV. Provider business mailing address

75 REMIT DR #1367
CHICAGO IL
60675-1367
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-5000
  • Fax:
Mailing address:
  • Phone: 866-916-5259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA.17111-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: