Healthcare Provider Details

I. General information

NPI: 1417998113
Provider Name (Legal Business Name): RICHARD A MORAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W CHAMBERS ST
MILWAUKEE WI
53210-1650
US

IV. Provider business mailing address

10625 W NORTH AVE 102
MILWAUKEE WI
53226-2315
US

V. Phone/Fax

Practice location:
  • Phone: 262-691-1940
  • Fax: 262-691-1126
Mailing address:
  • Phone: 414-877-5350
  • Fax: 414-877-5360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number33408
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33408
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: