Healthcare Provider Details

I. General information

NPI: 1992910830
Provider Name (Legal Business Name): EDWARD MORAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 WAYNE ST
FORT GAY WV
25514-8518
US

IV. Provider business mailing address

P.O. BOX 1680
HUNTINGTON WV
25717-1680
US

V. Phone/Fax

Practice location:
  • Phone: 304-648-5544
  • Fax:
Mailing address:
  • Phone: 304-697-1396
  • Fax: 304-697-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22569
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number22569
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22569
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: