Healthcare Provider Details

I. General information

NPI: 1740469873
Provider Name (Legal Business Name): RAYMOND W. MOY MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6917 W OKLAHOMA AVE
MILWAUKEE WI
53219-2973
US

IV. Provider business mailing address

6917 W OKLAHOMA AVE
MILWAUKEE WI
53219-2973
US

V. Phone/Fax

Practice location:
  • Phone: 414-545-7245
  • Fax: 414-545-3373
Mailing address:
  • Phone: 414-545-7245
  • Fax: 414-545-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number21142
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number21142
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21142
License Number StateWI

VIII. Authorized Official

Name: DEBBIE MOKELKE
Title or Position: BILLING
Credential:
Phone: 414-545-7245