Healthcare Provider Details

I. General information

NPI: 1538452966
Provider Name (Legal Business Name): CHARLOTTE MAY HARWOOD MORIARTY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HIGH ST
WAKEFIELD RI
02879-3103
US

IV. Provider business mailing address

1 HIGH ST
WAKEFIELD RI
02879-3103
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-1422
  • Fax: 401-782-6810
Mailing address:
  • Phone: 401-789-1422
  • Fax: 401-782-6810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301098575
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301098575
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD15220
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: